Healthcare Provider Details

I. General information

NPI: 1093074734
Provider Name (Legal Business Name): ERIN SUZANNE FORTUNA GCDF, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2012
Last Update Date: 05/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9844 DIXIE HWY
IRA MI
48023-2813
US

IV. Provider business mailing address

60 HUBBARD ST
MOUNT CLEMENS MI
48043-5517
US

V. Phone/Fax

Practice location:
  • Phone: 586-716-7600
  • Fax:
Mailing address:
  • Phone: 586-909-1798
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6401010920
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: