Provider Demographics
NPI:1124673561
Name:ERVINE, NICOLE (MSW, LSW)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:ERVINE
Suffix:
Gender:F
Credentials:MSW, LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1647 N WOOD CREEK DR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45458-9717
Mailing Address - Country:US
Mailing Address - Phone:937-623-7810
Mailing Address - Fax:
Practice Address - Street 1:4203 PENNYROYAL RD
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:OH
Practice Address - Zip Code:45005-1143
Practice Address - Country:US
Practice Address - Phone:937-623-7810
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-02
Last Update Date:2019-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.1000717104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty