Provider Demographics
NPI:1487173753
Name:IRVIN, ERICA DENISE
Entity type:Individual
Prefix:
First Name:ERICA
Middle Name:DENISE
Last Name:IRVIN
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 1:4681 MARSH HARBOR DR
Mailing Address - Street 2:
Mailing Address - City:TAVARES
Mailing Address - State:FL
Mailing Address - Zip Code:32778-4764
Mailing Address - Country:US
Mailing Address - Phone:352-602-1308
Mailing Address - Fax:
Practice Address - Street 1:4681 MARSH HARBOR DR
Practice Address - Street 2:
Practice Address - City:TAVARES
Practice Address - State:FL
Practice Address - Zip Code:32778
Practice Address - Country:US
Practice Address - Phone:352-602-1308
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL684300Medicaid