Provider Demographics
NPI:1861926149
Name:GERALDS, ERICA (MDIV, LPC, NCC)
Entity type:Individual
Prefix:
First Name:ERICA
Middle Name:
Last Name:GERALDS
Suffix:
Gender:F
Credentials:MDIV, LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4190 PEACE ROSE PL
Mailing Address - Street 2:
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-5112
Mailing Address - Country:US
Mailing Address - Phone:678-640-3196
Mailing Address - Fax:
Practice Address - Street 1:4190 PEACE ROSE PL
Practice Address - Street 2:
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052-5112
Practice Address - Country:US
Practice Address - Phone:678-640-3196
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-13
Last Update Date:2019-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.012703101YP2500X
GALPC011071101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1673042OtherBLUE CROSS BLUE SHIELD
IL2A00-IPI-178Medicaid
IL2A00-IPI-178Medicaid