Provider Demographics
NPI:1376722702
Name:TILSON, EDWARD FRANCIS (PHD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:FRANCIS
Last Name:TILSON
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 61637
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33906-1637
Mailing Address - Country:US
Mailing Address - Phone:239-265-6151
Mailing Address - Fax:
Practice Address - Street 1:3432 DEPEW AVE
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-7015
Practice Address - Country:US
Practice Address - Phone:239-265-6151
Practice Address - Fax:239-561-3646
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-01
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY4180103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL73456BMedicare PIN