Healthcare Provider Details

I. General information

NPI: 1467269191
Provider Name (Legal Business Name): ELIZABETH MARIE GERVAIS LMFTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/16/2024
Last Update Date: 12/16/2024
Certification Date: 12/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

547 COUNTY ROAD 1224
VINEMONT AL
35179-6595
US

IV. Provider business mailing address

547 COUNTY ROAD 1224
VINEMONT AL
35179-6595
US

V. Phone/Fax

Practice location:
  • Phone: 708-699-4480
  • Fax:
Mailing address:
  • Phone: 708-699-4480
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberA131
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: