Provider Demographics
NPI:1710246574
Name:ERWIN, FAMOUS
Entity Type:Individual
Prefix:
First Name:FAMOUS
Middle Name:
Last Name:ERWIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3150 CARDINAL DR
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32963-1931
Mailing Address - Country:US
Mailing Address - Phone:772-985-4941
Mailing Address - Fax:
Practice Address - Street 1:3150 CARDINAL DR
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32963-1931
Practice Address - Country:US
Practice Address - Phone:772-985-4941
Practice Address - Fax:772-365-2906
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-14
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
FL15574101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker