Provider Demographics
NPI:1790044915
Name:ERVIN, CRYSTAL (LPC)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:ERVIN
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 ASTERIA ST
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29607-6326
Mailing Address - Country:US
Mailing Address - Phone:864-315-8189
Mailing Address - Fax:864-412-8516
Practice Address - Street 1:1 CHICK SPRINGS RD STE 210A
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29609
Practice Address - Country:US
Practice Address - Phone:864-569-7344
Practice Address - Fax:864-412-8516
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-08
Last Update Date:2018-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP1600X
4012101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPC1961Medicaid