Provider Demographics
NPI:1144957143
Name:COURNOYER, ERICA RAE
Entity type:Individual
Prefix:
First Name:ERICA
Middle Name:RAE
Last Name:COURNOYER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ERICA
Other - Middle Name:R
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MSW, LICSW
Mailing Address - Street 1:28395 LAKESIDE WAY
Mailing Address - Street 2:
Mailing Address - City:LINDSTROM
Mailing Address - State:MN
Mailing Address - Zip Code:55045-4403
Mailing Address - Country:US
Mailing Address - Phone:651-329-9476
Mailing Address - Fax:
Practice Address - Street 1:18323 JULY AVE N
Practice Address - Street 2:
Practice Address - City:FOREST LAKE
Practice Address - State:MN
Practice Address - Zip Code:55025-9788
Practice Address - Country:US
Practice Address - Phone:651-329-9476
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-01
Last Update Date:2022-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN243361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical