MEDICARE: ERIN ELIZABETH MINOR CAP

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	4322	FL
2	101YM0800X	Mental Health Counselor	4322	FL

General Provider Information

NPI Number	:	1790937001
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ERIN ELIZABETH MINOR CAP

Provider Business Mailing Address
First Line	:	14167 CATTLE EGRET PL
Second Line	:
City	:	LAKEWOOD RANCH
State	:	FL
Zip	:	34202-8259
Country	:	US
Telephone Number	:	941-228-4310
Fax Number	:	941-954-2349

Provider Business Practice Location Address
First Line	:	209 N LIME AVE
Second Line	:
City	:	SARASOTA
State	:	FL
Zip	:	34237-6123
Country	:	US
Telephone Number	:	941-228-4310
Fax Number	:	941-954-2349

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

Provider Enumeration Date	:	10/17/2008
Last Update Date	:	10/17/2008

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