Provider Demographics
NPI:1629775846
Name:GORE, ERICA D
Entity Type:Individual
Prefix:
First Name:ERICA
Middle Name:D
Last Name:GORE
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 1:1533 DUXBERRY AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43211-1619
Mailing Address - Country:US
Mailing Address - Phone:614-357-1937
Mailing Address - Fax:
Practice Address - Street 1:1533 DUXBERRY AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43211-1619
Practice Address - Country:US
Practice Address - Phone:614-357-1937
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-08
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health
No261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
No322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children