Basic Information
Provider Information | |||||||||
NPI: | 1104020098 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WESEMAN | ||||||||
FirstName: | ERICA | ||||||||
MiddleName: | BOLIN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LCSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BOLIN | ||||||||
OtherFirstName: | ERICA | ||||||||
OtherMiddleName: | OPAL | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | LGSW | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 2409 HOMER CLAYTON DR | ||||||||
Address2: |   | ||||||||
City: | GUNTERSVILLE | ||||||||
State: | AL | ||||||||
PostalCode: | 359762207 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2565823203 | ||||||||
FaxNumber: | 2565823216 | ||||||||
Practice Location | |||||||||
Address1: | 9401 SOUTHWEST FWY | ||||||||
Address2: |   | ||||||||
City: | HOUSTON | ||||||||
State: | TX | ||||||||
PostalCode: | 770741407 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7139707000 | ||||||||
FaxNumber: | 7139707246 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/13/2007 | ||||||||
LastUpdateDate: | 05/01/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 2337G | AL | N |   | Behavioral Health & Social Service Providers | Social Worker |   | 101Y00000X | 2337G | AL | N |   | Behavioral Health & Social Service Providers | Counselor |   | 1041C0700X | 2248C | AL | N |   | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | 57303 | TX | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
ID | Type | State | Issuer | Description | 51541444 | 01 | AL | BCBS | OTHER | 312423201 | 05 | TX |   | MEDICAID |