Healthcare Provider Details

I. General information

NPI: 1003939356
Provider Name (Legal Business Name): KENNETH ANTHONY EDWARDS PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10116 HIGHWAY 50 EAST SUITE 101
MOUND HOUSE NV
89706
US

IV. Provider business mailing address

PO BOX 115
DAYTON NV
89403-0115
US

V. Phone/Fax

Practice location:
  • Phone: 775-841-3116
  • Fax:
Mailing address:
  • Phone: 775-841-3116
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPY0409
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number1167
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License NumberPY0409
License Number StateNV
# 4
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License Number1167
License Number StateWI
# 5
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License NumberPY0409
License Number StateNV
# 6
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number1167
License Number StateWI
# 7
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License NumberPY0409
License Number StateNV
# 8
Primary TaxonomyY
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License Number1167
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: