Provider Demographics
NPI:1700302007
Name:SUDDEATH, ERIC (MA, LPC)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:SUDDEATH
Suffix:
Gender:M
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4005 DAVIS DR
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-4279
Mailing Address - Country:US
Mailing Address - Phone:901-607-3705
Mailing Address - Fax:
Practice Address - Street 1:304 ENTERPRISE DR
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655-2762
Practice Address - Country:US
Practice Address - Phone:662-371-1711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-17
Last Update Date:2017-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2201101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor