Healthcare Provider Details

I. General information

NPI: 1043594104
Provider Name (Legal Business Name): RICHARD ERTTER M.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/06/2011
Last Update Date: 10/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

286 TRAPPER RIDGE LN
HEDGESVILLE WV
25427-7166
US

IV. Provider business mailing address

286 TRAPPER RIDGE LN
HEDGESVILLE WV
25427-7166
US

V. Phone/Fax

Practice location:
  • Phone: 540-331-1152
  • Fax:
Mailing address:
  • Phone: 540-331-1152
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLC3237
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: