Provider Demographics
NPI:1144765892
Name:MARTINO, ERICA DAWN (LLPC)
Entity Type:Individual
Prefix:
First Name:ERICA
Middle Name:DAWN
Last Name:MARTINO
Suffix:
Gender:F
Credentials:LLPC
Other - Prefix:
Other - First Name:ERICA
Other - Middle Name:DAWN
Other - Last Name:ROLLYSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11630 FULTON ST E
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:MI
Mailing Address - Zip Code:49331-9426
Mailing Address - Country:US
Mailing Address - Phone:616-481-3784
Mailing Address - Fax:866-496-2998
Practice Address - Street 1:11630 FULTON ST E
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MI
Practice Address - Zip Code:49331-9426
Practice Address - Country:US
Practice Address - Phone:616-481-3784
Practice Address - Fax:866-496-2998
Is Sole Proprietor?:No
Enumeration Date:2017-01-04
Last Update Date:2017-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401015864101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health