Provider Demographics
NPI:1578707212
Name:ERVIN, BRIAN K
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:K
Last Name:ERVIN
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 1:1700 W GOVERNMENT ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39042-2417
Mailing Address - Country:US
Mailing Address - Phone:601-454-4379
Mailing Address - Fax:601-829-9383
Practice Address - Street 1:430 BAY POINTE CIR
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:MS
Practice Address - Zip Code:39047-8553
Practice Address - Country:US
Practice Address - Phone:601-454-4379
Practice Address - Fax:601-829-9383
Is Sole Proprietor?:No
Enumeration Date:2009-04-24
Last Update Date:2014-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1946101YP2500X
MST0280106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist