MEDICARE: ERICA MORTIMER MA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	37LC00241100	NJ
2	101YP2500X	Professional Counselor	37C00533900	NJ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	37LC00241100	OTHER	NJ	LCADC LICENSE NUMBER
2	37PC00533900	OTHER	NJ	LPC LICENSE NUMBER

General Provider Information

NPI Number	:	1104310507
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ERICA MORTIMER MA

Provider Business Mailing Address
First Line	:	PO BOX 9899
Second Line	:
City	:	TRENTON
State	:	NJ
Zip	:	08650-1899
Country	:	US
Telephone Number	:	609-468-4419
Fax Number	:

Provider Business Practice Location Address
First Line	:	20 SCOTCH RD STE B
Second Line	:
City	:	EWING
State	:	NJ
Zip	:	08628-2529
Country	:	US
Telephone Number	:	888-500-9279
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/19/2018
Last Update Date	:	06/19/2018

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