Provider Demographics
NPI:1215683974
Name:HINES, ERICA RAYVON
Entity type:Individual
Prefix:
First Name:ERICA
Middle Name:RAYVON
Last Name:HINES
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 1:3105 SPRINGTIME LN APT 201
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63033-1667
Mailing Address - Country:US
Mailing Address - Phone:314-349-0560
Mailing Address - Fax:
Practice Address - Street 1:3105 SPRINGTIME LN APT 201
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63033-1667
Practice Address - Country:US
Practice Address - Phone:314-349-0560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-22
Last Update Date:2022-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0000000000OtherN/A