MEDICARE: RANDY L ERVIN LLC

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	103TC0700X	Clinical Psychologist

General Provider Information

NPI Number	:	1063221588
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RANDY L ERVIN LLC

Provider Business Mailing Address
First Line	:	PO BOX 473
Second Line	:
City	:	YORK
State	:	NE
Zip	:	68467-0473
Country	:	US
Telephone Number	:	316-230-7900
Fax Number	:

Provider Business Practice Location Address
First Line	:	727 N LINCOLN AVE STE 1
Second Line	:
City	:	YORK
State	:	NE
Zip	:	68467-2948
Country	:	US
Telephone Number	:	316-230-7900
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. RANDY LEE ERVIN
Credential	:	PSY.D.
Telephone Number	:	316-230-7900

Provider Enumeration Date	:	12/31/2024
Last Update Date	:	12/31/2024

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