Healthcare Provider Details

I. General information

NPI: 1487924171
Provider Name (Legal Business Name): CHAD ROBERT EDWARDS PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/11/2012
Last Update Date: 02/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

314 W CATALPA DR SUITE E
MISHAWAKA IN
46545-3194
US

IV. Provider business mailing address

10706 TRAILWOOD DR
FISHERS IN
46038-6514
US

V. Phone/Fax

Practice location:
  • Phone: 574-254-1700
  • Fax: 574-254-2930
Mailing address:
  • Phone: 574-855-7169
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number20042553A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: