Healthcare Provider Details

I. General information

NPI: 1841851508
Provider Name (Legal Business Name): RYAN ROSS ERVIN LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2019
Last Update Date: 12/09/2024
Certification Date: 12/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 554
HILO HI
96721-0554
US

IV. Provider business mailing address

PO BOX 554
HILO HI
96721-0554
US

V. Phone/Fax

Practice location:
  • Phone: 808-755-3072
  • Fax:
Mailing address:
  • Phone: 808-755-3072
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberL11132
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberL11132
License Number StateOR
# 4
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-5235
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: