MEDICARE: ERICA FARDETTE LAC

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	101YM0800X	Mental Health Counselor	LAC-22299	AZ

General Provider Information

NPI Number	:	1699532051
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ERICA FARDETTE LAC

Provider Business Mailing Address
First Line	:	2037 W BUTLER DR APT 204
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85021-4217
Country	:	US
Telephone Number	:	602-565-0620
Fax Number	:

Provider Business Practice Location Address
First Line	:	2901 E CAMELBACK RD STE 200
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85016-4420
Country	:	US
Telephone Number	:	602-777-6156
Fax Number	:	602-513-7303

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

Provider Enumeration Date	:	03/04/2024
Last Update Date	:	03/04/2024

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Directions to “ ERICA FARDETTE LAC” Practice Location

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