Provider Demographics
NPI:1700351780
Name:HAUSCHULZ, ERICA RAE
Entity Type:Individual
Prefix:
First Name:ERICA
Middle Name:RAE
Last Name:HAUSCHULZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ERICA
Other - Middle Name:
Other - Last Name:BERTRAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:900 7TH STREET
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:WA
Mailing Address - Zip Code:99403-2005
Mailing Address - Country:US
Mailing Address - Phone:509-758-3341
Mailing Address - Fax:
Practice Address - Street 1:1623 5TH STREET
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:WA
Practice Address - Zip Code:99403
Practice Address - Country:US
Practice Address - Phone:509-758-3341
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-05
Last Update Date:2022-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
WA175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA91-1156943Medicaid