Basic Information
| Provider Information | |||||||||
| NPI: | 1700830841 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ERVIN | ||||||||
| FirstName: | TAMMIE | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 107 CRANES ROOST CT | ||||||||
| Address2: | |||||||||
| City: | ELIZABETHTOWN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 427013650 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707652605 | ||||||||
| FaxNumber: | 2707661222 | ||||||||
| Practice Location | |||||||||
| Address1: | 607 OLD HIGHWAY 60 | ||||||||
| Address2: | |||||||||
| City: | HARDINSBURG | ||||||||
| State: | KY | ||||||||
| PostalCode: | 401432511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707565816 | ||||||||
| FaxNumber: | 2707565815 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 1840 | KY | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 11574914 | 01 | CAQH | OTHER | 30605018 | 05 | KY | MEDICAID |