Provider Demographics
NPI:1336911411
Name:EGNATOSKI, ERIKA AUTUMN
Entity Type:Individual
Prefix:
First Name:ERIKA
Middle Name:AUTUMN
Last Name:EGNATOSKI
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 1:264 HOLLISTER AVE SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506-1463
Mailing Address - Country:US
Mailing Address - Phone:586-719-9145
Mailing Address - Fax:
Practice Address - Street 1:3300 36TH ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49512-2810
Practice Address - Country:US
Practice Address - Phone:616-942-2110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-23
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician