Provider Demographics
NPI:1598912651
Name:HAINES, ERICA DIANE (MA, CCC/SLP)
Entity type:Individual
Prefix:MISS
First Name:ERICA
Middle Name:DIANE
Last Name:HAINES
Suffix:
Gender:F
Credentials:MA, CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 HUNTINGTON PLACE DR
Mailing Address - Street 2:
Mailing Address - City:GLEN CARBON
Mailing Address - State:IL
Mailing Address - Zip Code:62034-3050
Mailing Address - Country:US
Mailing Address - Phone:217-972-7027
Mailing Address - Fax:
Practice Address - Street 1:11160 VILLAGE NORTH DR
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63136-6159
Practice Address - Country:US
Practice Address - Phone:314-355-8010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-20
Last Update Date:2016-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.009550235Z00000X
MO2012040944235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist