Provider Demographics
NPI:1790199297
Name:GRESHAM, ERICKA
Entity Type:Individual
Prefix:
First Name:ERICKA
Middle Name:
Last Name:GRESHAM
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 1:3738 W NANCY LN
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85041-5030
Mailing Address - Country:US
Mailing Address - Phone:602-476-9954
Mailing Address - Fax:
Practice Address - Street 1:3738 W NANCY LN
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85041-5030
Practice Address - Country:US
Practice Address - Phone:602-476-9954
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-12
Last Update Date:2014-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor