Provider Demographics
NPI:1093236846
Name:HARPER, EDWIN TROY
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:TROY
Last Name:HARPER
Suffix:
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 1:768 SE LANSDOWNE AVE
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34983-3863
Mailing Address - Country:US
Mailing Address - Phone:772-528-8698
Mailing Address - Fax:
Practice Address - Street 1:1860 SW FOUNTAINVIEW BLVD STE 100
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986-4528
Practice Address - Country:US
Practice Address - Phone:772-494-8007
Practice Address - Fax:772-494-8007
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-02
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician