=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124039268
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EDWIN C OLIVER PSY D
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/11/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2220 SAINT PAUL ST
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21218-5805
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-261-5500
-----------------------------------------------------
Fax | 410-366-7680
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3300 NORTH RIDGE ROAD SUITE 110
-----------------------------------------------------
City | ELLICOTT CITY
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21043
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-561-9584
-----------------------------------------------------
Fax | 410-750-3330
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 3777
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------