Provider Demographics
NPI:1043594104
Name:ERTTER, RICHARD (MA)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:ERTTER
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:286 TRAPPER RIDGE LN
Mailing Address - Street 2:
Mailing Address - City:HEDGESVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:25427-7166
Mailing Address - Country:US
Mailing Address - Phone:540-331-1152
Mailing Address - Fax:
Practice Address - Street 1:286 TRAPPER RIDGE LN
Practice Address - Street 2:
Practice Address - City:HEDGESVILLE
Practice Address - State:WV
Practice Address - Zip Code:25427-7166
Practice Address - Country:US
Practice Address - Phone:540-331-1152
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-06
Last Update Date:2014-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC3237101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDLC3237OtherLICENSED CLINICAL PROFESSIONAL COUNSELOR