Provider Demographics
NPI:1699532051
Name:FARDETTE, ERICA (LAC)
Entity type:Individual
Prefix:
First Name:ERICA
Middle Name:
Last Name:FARDETTE
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2037 W BUTLER DR APT 204
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85021-4217
Mailing Address - Country:US
Mailing Address - Phone:602-565-0620
Mailing Address - Fax:
Practice Address - Street 1:2901 E CAMELBACK RD STE 200
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-4420
Practice Address - Country:US
Practice Address - Phone:602-777-6156
Practice Address - Fax:602-513-7303
Is Sole Proprietor?:No
Enumeration Date:2024-03-04
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-22299101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health