Provider Demographics
NPI:1316579964
Name:BRAGG, ERICA TIFFANY
Entity Type:Individual
Prefix:
First Name:ERICA
Middle Name:TIFFANY
Last Name:BRAGG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:199 W TRAFFORD ST
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90805-2145
Mailing Address - Country:US
Mailing Address - Phone:562-233-8715
Mailing Address - Fax:
Practice Address - Street 1:1720 E 120TH ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90059-3052
Practice Address - Country:US
Practice Address - Phone:310-668-4272
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-11
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6855101YM0800X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health