Provider Demographics
NPI:1619575354
Name:CROSS, ERICA
Entity Type:Individual
Prefix:
First Name:ERICA
Middle Name:
Last Name:CROSS
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 1:2650 SUZANNE WAY STE 200
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97408-7619
Mailing Address - Country:US
Mailing Address - Phone:541-345-2800
Mailing Address - Fax:541-345-4419
Practice Address - Street 1:2650 SUZANNE WAY STE 120
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97408-7619
Practice Address - Country:US
Practice Address - Phone:541-134-5280
Practice Address - Fax:541-345-4419
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-14
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
OR390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORPENDINGMedicaid