Healthcare Provider Details

I. General information

NPI: 1639479926
Provider Name (Legal Business Name): EDWARD BALBACH HEYDEN ED.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2010
Last Update Date: 11/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3180 S OCEAN DR 1001
HALLANDALE BEACH FL
33009-7255
US

IV. Provider business mailing address

3180 S OCEAN DR 1001
HALLANDALE BEACH FL
33009-7255
US

V. Phone/Fax

Practice location:
  • Phone: 954-673-5743
  • Fax:
Mailing address:
  • Phone: 954-673-5743
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPY8121
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberB116
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: