1275058273 NPI number — MRS. ERICA ROSE CREIGHTON LICSW

Table of content: MRS. ERICA ROSE CREIGHTON LICSW (NPI 1275058273)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275058273 NPI number — MRS. ERICA ROSE CREIGHTON LICSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CREIGHTON
Provider First Name:
ERICA
Provider Middle Name:
ROSE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LICSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BERGER
Provider Other First Name:
ERICA
Provider Other Middle Name:
ROSE
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
LICSW
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1275058273
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/21/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2925 CHICAGO AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MINNEAPOLIS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55407-1321
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-262-9000
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
303 CATLIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BUFFALO
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55313-1947
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-682-5225
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/10/2017

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  21137 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)