Provider Demographics
NPI:1093077638
Name:HUSTON, EDWIN JR
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:
Last Name:HUSTON
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5900 SAWMILL RD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43017-3538
Mailing Address - Country:US
Mailing Address - Phone:614-717-9652
Mailing Address - Fax:614-717-9657
Practice Address - Street 1:5900 SAWMILL RD
Practice Address - Street 2:SUITE 210
Practice Address - City:DUBLIN
Practice Address - State:OH
Practice Address - Zip Code:43017-3538
Practice Address - Country:US
Practice Address - Phone:614-717-9652
Practice Address - Fax:614-717-9657
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-11
Last Update Date:2012-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0700340101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional