Provider Demographics
NPI:1154194934
Name:PTAK, ERIKA
Entity type:Individual
Prefix:
First Name:ERIKA
Middle Name:
Last Name:PTAK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13524 WANSTEADT PL
Mailing Address - Street 2:
Mailing Address - City:BRISTOW
Mailing Address - State:VA
Mailing Address - Zip Code:20136-5729
Mailing Address - Country:US
Mailing Address - Phone:703-994-2828
Mailing Address - Fax:
Practice Address - Street 1:7440 HERITAGE VILLAGE PLZ STE 102
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:VA
Practice Address - Zip Code:20155-3081
Practice Address - Country:US
Practice Address - Phone:703-994-2828
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-02
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701012887101Y00000X, 101YM0800X, 101YP2500X
VA101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool