Healthcare Provider Details

I. General information

NPI: 1538790910
Provider Name (Legal Business Name): KRISTINE ELIZABETH GERVASI LLPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/04/2020
Last Update Date: 05/07/2025
Certification Date: 05/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 E MAIN ST STE 3
NILES MI
49120-2376
US

IV. Provider business mailing address

210 E MAIN ST STE 3
NILES MI
49120-2376
US

V. Phone/Fax

Practice location:
  • Phone: 269-340-2770
  • Fax:
Mailing address:
  • Phone: 269-340-2770
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6451024195
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: