Provider Demographics
NPI:1982230934
Name:ERVIN, VERNA (CATC)
Entity Type:Individual
Prefix:
First Name:VERNA
Middle Name:
Last Name:ERVIN
Suffix:
Gender:F
Credentials:CATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 ALASKA AVE APT 12
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94533-7432
Mailing Address - Country:US
Mailing Address - Phone:707-384-4917
Mailing Address - Fax:
Practice Address - Street 1:1601 2ND ST STE 104
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-2701
Practice Address - Country:US
Practice Address - Phone:415-456-6655
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-20
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA480010BN101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty