Provider Demographics
NPI:1912231218
Name:ERVIN, ELLEN SUE (LCSW, BCD)
Entity Type:Individual
Prefix:MS
First Name:ELLEN
Middle Name:SUE
Last Name:ERVIN
Suffix:
Gender:F
Credentials:LCSW, BCD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:347 PACIFIC ST
Mailing Address - Street 2:APT. 4A
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11217-2240
Mailing Address - Country:US
Mailing Address - Phone:917-319-7084
Mailing Address - Fax:
Practice Address - Street 1:345 ADAMS ST
Practice Address - Street 2:8TH FLOOR
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-3719
Practice Address - Country:US
Practice Address - Phone:718-260-8514
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-21
Last Update Date:2009-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR052655-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical