Provider Demographics
NPI:1790788206
Name:ERVIN, MARINA L (MS, LPC, NCC, BCPCC)
Entity Type:Individual
Prefix:
First Name:MARINA
Middle Name:L
Last Name:ERVIN
Suffix:
Gender:F
Credentials:MS, LPC, NCC, BCPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:502N EAST CORNWALLIS DR
Mailing Address - Street 2:STE B
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27405-5677
Mailing Address - Country:US
Mailing Address - Phone:336-681-1086
Mailing Address - Fax:336-370-0257
Practice Address - Street 1:502N EAST CORNWALLIS DR
Practice Address - Street 2:STE B
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27405-5677
Practice Address - Country:US
Practice Address - Phone:336-681-1086
Practice Address - Fax:336-370-0257
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-30
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC47974 NCC101YP2500X
NC3425 LPC101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6102031Medicaid
NC131APOtherBCBS/NC HEALTH CHOICE