Provider Demographics
NPI:1700830841
Name:ERVIN, TAMMIE (LCSW)
Entity Type:Individual
Prefix:
First Name:TAMMIE
Middle Name:
Last Name:ERVIN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 CRANES ROOST CT
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-3650
Mailing Address - Country:US
Mailing Address - Phone:270-765-2605
Mailing Address - Fax:270-766-1222
Practice Address - Street 1:607 OLD HIGHWAY 60
Practice Address - Street 2:
Practice Address - City:HARDINSBURG
Practice Address - State:KY
Practice Address - Zip Code:40143-2511
Practice Address - Country:US
Practice Address - Phone:270-756-5816
Practice Address - Fax:270-756-5815
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY18401041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
11574914OtherCAQH
KY30605018Medicaid
KY30605018Medicaid
0358882Medicare ID - Type Unspecified