Provider Demographics
NPI:1235113135
Name:ZDENEK, EDWARD J (SCD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:J
Last Name:ZDENEK
Suffix:
Gender:M
Credentials:SCD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:770 WASHINGTON ST.
Mailing Address - Street 2:SUITE 3
Mailing Address - City:HOLLISTON
Mailing Address - State:MA
Mailing Address - Zip Code:01746
Mailing Address - Country:US
Mailing Address - Phone:508-429-7311
Mailing Address - Fax:
Practice Address - Street 1:770 WASHINGTON ST.
Practice Address - Street 2:SUITE 3
Practice Address - City:HOLLISTON
Practice Address - State:MA
Practice Address - Zip Code:01746
Practice Address - Country:US
Practice Address - Phone:508-429-7311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-04
Last Update Date:2011-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2784103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAR44378Medicare UPIN
MAWO2942Medicare ID - Type UnspecifiedPROVIDER PSYCHOLOGIST
R44378Medicare UPIN