Healthcare Provider Details

I. General information

NPI: 1912387010
Provider Name (Legal Business Name): ERICA IRONSIDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2015
Last Update Date: 06/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 E 1ST ST
NEWBERG OR
97132-2909
US

IV. Provider business mailing address

2882 NW OVERLOOK DR APT. 1826
HILLSBORO OR
97124-7685
US

V. Phone/Fax

Practice location:
  • Phone: 503-538-4874
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: