Provider Demographics
NPI:1467918219
Name:EDELEN, MISTI POWELL (MED)
Entity Type:Individual
Prefix:
First Name:MISTI
Middle Name:POWELL
Last Name:EDELEN
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 OXFORD PL
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-2922
Mailing Address - Country:US
Mailing Address - Phone:502-819-9001
Mailing Address - Fax:
Practice Address - Street 1:1028 MAIN ST
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:KY
Practice Address - Zip Code:40065-1315
Practice Address - Country:US
Practice Address - Phone:502-647-2477
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-18
Last Update Date:2019-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling