Provider Demographics
NPI:1669949053
Name:VERNON, ERICKA (CCTP-II)
Entity type:Individual
Prefix:
First Name:ERICKA
Middle Name:
Last Name:VERNON
Suffix:
Gender:F
Credentials:CCTP-II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 MONUMENT PL
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08618-3955
Mailing Address - Country:US
Mailing Address - Phone:800-702-7726
Mailing Address - Fax:
Practice Address - Street 1:276 5TH AVE RM 704
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001-4527
Practice Address - Country:US
Practice Address - Phone:800-702-7726
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-24
Last Update Date:2020-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYACTIVE172V00000X, 101YM0800X, 101YM0800X
NJACTIVE-SEALED2084B0040X, 103K00000X, 102L00000X, 222Q00000X, 103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No172V00000XOther Service ProvidersCommunity Health WorkerGroup - Multi-Specialty
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No2084B0040XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyBehavioral Neurology & NeuropsychiatryGroup - Multi-Specialty
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No102L00000XBehavioral Health & Social Service ProvidersPsychoanalystGroup - Multi-Specialty
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist