Provider Demographics
NPI:1124663695
Name:TRAVERS, ERICKA TIDMORE (LCPC-C, LADC, CCS)
Entity type:Individual
Prefix:
First Name:ERICKA
Middle Name:TIDMORE
Last Name:TRAVERS
Suffix:
Gender:F
Credentials:LCPC-C, LADC, CCS
Other - Prefix:
Other - First Name:ERICKA
Other - Middle Name:MICHELLE
Other - Last Name:TIDMORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:26 SPRING ST
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-6817
Mailing Address - Country:US
Mailing Address - Phone:207-561-7269
Mailing Address - Fax:
Practice Address - Street 1:26 SPRING ST
Practice Address - Street 2:
Practice Address - City:BELFAST
Practice Address - State:ME
Practice Address - Zip Code:04915-6817
Practice Address - Country:US
Practice Address - Phone:207-561-7269
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-08
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC7487101YA0400X
MEXL6874101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)