Provider Demographics
NPI:1477617793
Name:ERVIN, ANTOINETTE CARLA (LSW-C)
Entity Type:Individual
Prefix:MRS
First Name:ANTOINETTE
Middle Name:CARLA
Last Name:ERVIN
Suffix:
Gender:F
Credentials:LSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 COMMERCE DR
Mailing Address - Street 2:
Mailing Address - City:SKOWHEGAN
Mailing Address - State:ME
Mailing Address - Zip Code:04976-4823
Mailing Address - Country:US
Mailing Address - Phone:207-626-3478
Mailing Address - Fax:207-626-7586
Practice Address - Street 1:72 WINTHROP ST
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:ME
Practice Address - Zip Code:04330-5500
Practice Address - Country:US
Practice Address - Phone:207-626-3478
Practice Address - Fax:207-626-7586
Is Sole Proprietor?:No
Enumeration Date:2006-12-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELSX3879104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker