=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700250818
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ESTHER ERVIN LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/01/2015
-----------------------------------------------------
Last Update Date | 12/12/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 50 CLAY ST STE. 3
-----------------------------------------------------
City | MORGANTOWN
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26501-5932
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-381-4831
-----------------------------------------------------
Fax | 304-381-4826
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 47 PRICE HILL RD
-----------------------------------------------------
City | MORGANTOWN
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26501-2319
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-680-5199
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 2203
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 2203
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------