Provider Demographics
NPI:1972228559
Name:ERVIN, RANDY LEE (PSYD)
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:LEE
Last Name:ERVIN
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:223 E 8TH ST
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:NE
Mailing Address - Zip Code:68467-3040
Mailing Address - Country:US
Mailing Address - Phone:402-710-0564
Mailing Address - Fax:833-382-0104
Practice Address - Street 1:223 E 8TH ST
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:NE
Practice Address - Zip Code:68467-3040
Practice Address - Country:US
Practice Address - Phone:402-710-0564
Practice Address - Fax:833-382-0104
Is Sole Proprietor?:No
Enumeration Date:2022-10-06
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE708103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist