Provider Demographics
NPI:1871085183
Name:SUMMERS, ERIC
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:SUMMERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:835 E WANDERING LN APT 103
Mailing Address - Street 2:
Mailing Address - City:KUNA
Mailing Address - State:ID
Mailing Address - Zip Code:83634-5476
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4633 OLD IRONSIDES DR STE 304
Practice Address - Street 2:
Practice Address - City:SANTA CLARA
Practice Address - State:CA
Practice Address - Zip Code:95054
Practice Address - Country:US
Practice Address - Phone:323-205-7088
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-01
Last Update Date:2024-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
IDLPC-9762101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician