Healthcare Provider Details

I. General information

NPI: 1710366976
Provider Name (Legal Business Name): ERICKA GONZALEZ CARRILLO M.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2015
Last Update Date: 09/25/2023
Certification Date: 09/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1985 MAIN ST STE E
SPRINGFIELD MA
01103-1016
US

IV. Provider business mailing address

1985 MAIN ST STE E
SPRINGFIELD MA
01103-1016
US

V. Phone/Fax

Practice location:
  • Phone: 413-361-4587
  • Fax: 413-788-0626
Mailing address:
  • Phone: 413-361-4587
  • Fax: 413-788-0626

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number18240
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: