Provider Demographics
NPI:1962414722
Name:O'NEAL, ERICA
Entity type:Individual
Prefix:
First Name:ERICA
Middle Name:
Last Name:O'NEAL
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:PO BOX 11051
Mailing Address - Street 2:
Mailing Address - City:YELLOWKNIFE
Mailing Address - State:NT
Mailing Address - Zip Code:X1A 0E3
Mailing Address - Country:CA
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:900 LARKSPUR LANDING CIR STE 160
Practice Address - Street 2:
Practice Address - City:LARKSPUR
Practice Address - State:CA
Practice Address - Zip Code:94939-1766
Practice Address - Country:US
Practice Address - Phone:707-258-8757
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2023-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042-00110442084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTD011466Medicaid