Provider Demographics
NPI:1831800663
Name:ERVIN, LANIQUE (P-LPC)
Entity type:Individual
Prefix:
First Name:LANIQUE
Middle Name:
Last Name:ERVIN
Suffix:
Gender:F
Credentials:P-LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 GOODMAN RD E STE 204
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-8313
Mailing Address - Country:US
Mailing Address - Phone:662-985-1844
Mailing Address - Fax:
Practice Address - Street 1:230 GOODMAN RD E STE 204
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-8313
Practice Address - Country:US
Practice Address - Phone:662-985-1844
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-13
Last Update Date:2022-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health