Provider Demographics
NPI:1275506255
Name:PETREE, ERICA (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:ERICA
Middle Name:
Last Name:PETREE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 N BOONE ST STE 102
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-5675
Mailing Address - Country:US
Mailing Address - Phone:619-839-9730
Mailing Address - Fax:
Practice Address - Street 1:207 N BOONE ST STE 102
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-5675
Practice Address - Country:US
Practice Address - Phone:619-839-9730
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-09
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA60460101YM0800X
TX41439104100000X
TN76661041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX091740301Medicaid