Provider Demographics
NPI:1689734642
Name:ELSEN, ERIN MEG (LPC)
Entity Type:Individual
Prefix:MS
First Name:ERIN
Middle Name:MEG
Last Name:ELSEN
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:MRS
Other - First Name:ERIN
Other - Middle Name:MEG
Other - Last Name:BERTKE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LPC
Mailing Address - Street 1:2621 OAKWOOD DR SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506-4230
Mailing Address - Country:US
Mailing Address - Phone:616-285-6114
Mailing Address - Fax:
Practice Address - Street 1:40 JEFFERSON AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4304
Practice Address - Country:US
Practice Address - Phone:616-356-6285
Practice Address - Fax:616-732-6392
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401009953101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI7905106890Medicare UPIN