MEDICARE: ERIC KID QUICK LPC, LAC, LMHC

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	175	CO
2	101YM0800X	Mental Health Counselor	6484	CO
3	101YM0800X	Mental Health Counselor	MH14257	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1194142943
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ERIC KID QUICK LPC, LAC, LMHC

Provider Business Mailing Address
First Line	:	1497 FOREST HILL BLVD STE E
Second Line	:
City	:	LAKE CLARKE SHORES
State	:	FL
Zip	:	33406-6052
Country	:	US
Telephone Number	:	561-433-5687
Fax Number	:	561-433-5705

Provider Business Practice Location Address
First Line	:	1497 FOREST HILL BLVD STE E
Second Line	:
City	:	LAKE CLARKE SHORES
State	:	FL
Zip	:	33406-6052
Country	:	US
Telephone Number	:	561-433-5687
Fax Number	:	561-433-5705

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

Provider Enumeration Date	:	03/18/2014
Last Update Date	:	03/12/2019

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