Provider Demographics
NPI:1942764402
Name:WEATHERFORD, ERICA
Entity Type:Individual
Prefix:
First Name:ERICA
Middle Name:
Last Name:WEATHERFORD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ERICA
Other - Middle Name:
Other - Last Name:POYNER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2809 FOREST HOME RD
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-5320
Mailing Address - Country:US
Mailing Address - Phone:866-972-1268
Mailing Address - Fax:
Practice Address - Street 1:2420 LINWOOD DR STE 1
Practice Address - Street 2:
Practice Address - City:PARAGOULD
Practice Address - State:AR
Practice Address - Zip Code:72450-6122
Practice Address - Country:US
Practice Address - Phone:870-236-5880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-29
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR231567795Medicaid