Healthcare Provider Details

I. General information

NPI: 1619307915
Provider Name (Legal Business Name): MRS. ERICA REGINA GRIFFIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2013
Last Update Date: 04/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2204 PACIFIC AVE N
LONG BEACH WA
98631-3300
US

IV. Provider business mailing address

2204 PACIFIC AVE N
LONG BEACH WA
98631-3300
US

V. Phone/Fax

Practice location:
  • Phone: 360-642-3787
  • Fax: 360-642-2096
Mailing address:
  • Phone: 360-642-3787
  • Fax: 360-642-2096

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberCG 60710317
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC007543
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: