Provider Demographics
NPI:1063891992
Name:ERVIN, RUCHITA
Entity type:Individual
Prefix:
First Name:RUCHITA
Middle Name:
Last Name:ERVIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1955 W BROADWAY STE 104
Mailing Address - Street 2:
Mailing Address - City:MONONA
Mailing Address - State:WI
Mailing Address - Zip Code:53713-3700
Mailing Address - Country:US
Mailing Address - Phone:608-405-3002
Mailing Address - Fax:
Practice Address - Street 1:1955 W BROADWAY STE 104
Practice Address - Street 2:
Practice Address - City:MONONA
Practice Address - State:WI
Practice Address - Zip Code:53713-3700
Practice Address - Country:US
Practice Address - Phone:608-405-3002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-26
Last Update Date:2025-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI17263-130101YA0400X
WI440-228106H00000X
WI6487-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist