Basic Information
| Provider Information | |||||||||
| NPI: | 1265039747 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MEDEIROS | ||||||||
| FirstName: | ERIN | ||||||||
| MiddleName: | EDWARDS | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LLPC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | EDWARDS | ||||||||
| OtherFirstName: | ERIN | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | LLPC | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1100 TORREY RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | FENTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 484303327 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8104947180 | ||||||||
| FaxNumber: | 8102151334 | ||||||||
| Practice Location | |||||||||
| Address1: | 2200 GENOA BUSINESS PARK DR STE 100 | ||||||||
| Address2: | |||||||||
| City: | BRIGHTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481145328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8104947180 | ||||||||
| FaxNumber: | 8102151334 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/07/2020 | ||||||||
| LastUpdateDate: | 10/07/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.