Provider Demographics
NPI:1245331172
Name:ERVIN, LEE JAMES (PHD)
Entity type:Individual
Prefix:DR
First Name:LEE
Middle Name:JAMES
Last Name:ERVIN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2020 STANDIFORD AVE
Mailing Address - Street 2:SUITE E-1
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-6529
Mailing Address - Country:US
Mailing Address - Phone:209-529-2084
Mailing Address - Fax:
Practice Address - Street 1:2020 STANDIFORD AVE
Practice Address - Street 2:SUITE E-1
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-6529
Practice Address - Country:US
Practice Address - Phone:209-529-2084
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY8985103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical