Healthcare Provider Details

I. General information

NPI: 1265687529
Provider Name (Legal Business Name): ERICA LENN SEAGRAVE CNIM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2008
Last Update Date: 01/23/2025
Certification Date: 01/23/2025
Deactivation Date: 09/26/2018
Reactivation Date: 04/14/2022

III. Provider practice location address

2500 DALLAS PKWY STE 500
PLANO TX
75093-4805
US

IV. Provider business mailing address

17025 E LA MONTANA DR UNIT 132
FOUNTAIN HILLS AZ
85268-8583
US

V. Phone/Fax

Practice location:
  • Phone: 317-503-1350
  • Fax:
Mailing address:
  • Phone: 317-503-1350
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2472E0500X
TaxonomyEEG Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code246ZE0600X
TaxonomyElectroneurodiagnostic Specialist/Technologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: