Provider Demographics
NPI:1144767443
Name:WHITEHURST, ERICA JEAN (LCSW)
Entity Type:Individual
Prefix:
First Name:ERICA
Middle Name:JEAN
Last Name:WHITEHURST
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:ERICA
Other - Middle Name:JEAN
Other - Last Name:JOHANSSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:30 SOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-3845
Mailing Address - Country:US
Mailing Address - Phone:631-979-1868
Mailing Address - Fax:
Practice Address - Street 1:30 SOUTH AVE
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-3845
Practice Address - Country:US
Practice Address - Phone:631-979-1868
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-24
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR049136-11041C0700X
NY6298940511041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool