Provider Demographics
NPI:1518077007
Name:SPAIN, EDWARD HULAND (PH D)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:HULAND
Last Name:SPAIN
Suffix:
Gender:M
Credentials:PH D
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 1066
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23439-1066
Mailing Address - Country:US
Mailing Address - Phone:757-539-9458
Mailing Address - Fax:757-539-9468
Practice Address - Street 1:424 N MAIN ST
Practice Address - Street 2:SUITE #4
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434-4428
Practice Address - Country:US
Practice Address - Phone:757-539-9458
Practice Address - Fax:757-539-9468
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810002426103G00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA088631OtherSENTARA
VA283200OtherBLUE CROSS BLUE SHIELD
VA443602OtherPHP-MD, MAMSI, ETC. NUMBE
VA088631OtherSENTARA