MEDICARE: ERICA GERALDS MDIV, LPC, NCC

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	101YP2500X	Professional Counselor	178.012703	IL
2	101Y00000X	Counselor	LPC011071	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1673042	OTHER	IL	BLUE CROSS BLUE SHIELD
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1861926149
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ERICA GERALDS MDIV, LPC, NCC

Provider Business Mailing Address
First Line	:	4190 PEACE ROSE PL
Second Line	:
City	:	LOGANVILLE
State	:	GA
Zip	:	30052-5112
Country	:	US
Telephone Number	:	678-640-3196
Fax Number	:

Provider Business Practice Location Address
First Line	:	4190 PEACE ROSE PL
Second Line	:
City	:	LOGANVILLE
State	:	GA
Zip	:	30052-5112
Country	:	US
Telephone Number	:	678-640-3196
Fax Number	:

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

Provider Enumeration Date	:	04/13/2017
Last Update Date	:	11/26/2019

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