MEDICARE: RYAN ROSS ERVIN LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	L11132	OR
2	1041C0700X	Clinical Social Worker	LCSW-5235	HI
3	101YA0400X	Addiction (Substance Use Disorder) Counselor
4	104100000X	Social Worker	L11132	OR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1841851508
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RYAN ROSS ERVIN LCSW

Provider Business Mailing Address
First Line	:	PO BOX 554
Second Line	:
City	:	HILO
State	:	HI
Zip	:	96721-0554
Country	:	US
Telephone Number	:	808-755-3072
Fax Number	:

Provider Business Practice Location Address
First Line	:	PO BOX 554
Second Line	:
City	:	HILO
State	:	HI
Zip	:	96721-0554
Country	:	US
Telephone Number	:	808-755-3072
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/24/2019
Last Update Date	:	12/09/2024

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