Provider Demographics
NPI:1285820472
Name:ERVIN, TANISHA ANNETTE
Entity Type:Individual
Prefix:
First Name:TANISHA
Middle Name:ANNETTE
Last Name:ERVIN
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 1:8626 LOWER SACRAMENTO RD
Mailing Address - Street 2:SUITE 41
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95210-1835
Mailing Address - Country:US
Mailing Address - Phone:209-478-2487
Mailing Address - Fax:
Practice Address - Street 1:8626 LOWER SACRAMENTO RD
Practice Address - Street 2:SUITE 41
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95210-1835
Practice Address - Country:US
Practice Address - Phone:209-478-2487
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-20
Last Update Date:2007-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)