Provider Demographics
NPI:1336119726
Name:CHANDLER, EDWARD WILLIAM (PHD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:WILLIAM
Last Name:CHANDLER
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 1:124 E MIRACLE STRIP PKWY
Mailing Address - Street 2:SUITE 302
Mailing Address - City:MARY ESTHER
Mailing Address - State:FL
Mailing Address - Zip Code:32569-1988
Mailing Address - Country:US
Mailing Address - Phone:850-243-8086
Mailing Address - Fax:850-243-2702
Practice Address - Street 1:124 E MIRACLE STRIP PKWY
Practice Address - Street 2:SUITE 302
Practice Address - City:MARY ESTHER
Practice Address - State:FL
Practice Address - Zip Code:32569-1988
Practice Address - Country:US
Practice Address - Phone:850-243-8086
Practice Address - Fax:850-243-2702
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2021-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY00003183103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL75209OtherBCBS
FL59-3736816OtherTAX ID NUMBER
FLK3215Medicare ID - Type UnspecifiedGROUP NUMBER
FL59-3736816OtherTAX ID NUMBER