Provider Demographics
NPI:1952344681
Name:EDWARDS, KEVIN J (PHD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:J
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 602
Mailing Address - Street 2:
Mailing Address - City:THORNVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43076-0602
Mailing Address - Country:US
Mailing Address - Phone:740-246-4963
Mailing Address - Fax:
Practice Address - Street 1:12 B WEST COLUMBUS ST
Practice Address - Street 2:
Practice Address - City:THORNVILLE
Practice Address - State:OH
Practice Address - Zip Code:43076-0602
Practice Address - Country:US
Practice Address - Phone:740-246-4963
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-13
Last Update Date:2009-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5679103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical