Healthcare Provider Details

I. General information

NPI: 1457340952
Provider Name (Legal Business Name): EDWIN H. REISFELD PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/18/2005
Last Update Date: 08/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15720 JOHN J DELANEY DR SUITE 300
CHARLOTTE NC
28277-3430
US

IV. Provider business mailing address

52511 WINCHESTER STREET
FORT MILL SC
29707
US

V. Phone/Fax

Practice location:
  • Phone: 704-927-5881
  • Fax: 704-944-3201
Mailing address:
  • Phone: 704-927-5881
  • Fax: 704-944-3201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number3748
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: