Provider Demographics
NPI:1992461198
Name:ERVIN, WESLEY-MARTIN
Entity type:Individual
Prefix:
First Name:WESLEY-MARTIN
Middle Name:
Last Name:ERVIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:920 REDWOOD LN
Mailing Address - Street 2:
Mailing Address - City:LEMOORE
Mailing Address - State:CA
Mailing Address - Zip Code:93245-3746
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:920 REDWOOD LN
Practice Address - Street 2:
Practice Address - City:LEMOORE
Practice Address - State:CA
Practice Address - Zip Code:93245-3746
Practice Address - Country:US
Practice Address - Phone:559-904-0977
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-11
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106H00000X
CA144361106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty