Healthcare Provider Details

I. General information

NPI: 1952344681
Provider Name (Legal Business Name): KEVIN J EDWARDS PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 03/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 B WEST COLUMBUS ST
THORNVILLE OH
43076-0602
US

IV. Provider business mailing address

PO BOX 602
THORNVILLE OH
43076-0602
US

V. Phone/Fax

Practice location:
  • Phone: 740-246-4963
  • Fax:
Mailing address:
  • Phone: 740-246-4963
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number5679
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: