Provider Demographics
NPI:1942764402
Name:WEATHERFORD, ERICA
Entity type:Individual
Prefix:
First Name:ERICA
Middle Name:
Last Name:WEATHERFORD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ERICA
Other - Middle Name:
Other - Last Name:POYNER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3305 E HIGHLAND DR STE B
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-6491
Mailing Address - Country:US
Mailing Address - Phone:870-520-5014
Mailing Address - Fax:
Practice Address - Street 1:3305 E HIGHLAND DR STE B
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-6491
Practice Address - Country:US
Practice Address - Phone:870-520-5014
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-29
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR231567795Medicaid