Provider Demographics
NPI:1528032083
Name:EDQUIST, MANUEL HARTY (PHD)
Entity Type:Individual
Prefix:
First Name:MANUEL
Middle Name:HARTY
Last Name:EDQUIST
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 1:517 LAKE DR
Mailing Address - Street 2:
Mailing Address - City:CHINA SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:76633-2631
Mailing Address - Country:US
Mailing Address - Phone:254-315-5761
Mailing Address - Fax:
Practice Address - Street 1:517 LAKE DR
Practice Address - Street 2:
Practice Address - City:CHINA SPRING
Practice Address - State:TX
Practice Address - Zip Code:76633-2631
Practice Address - Country:US
Practice Address - Phone:254-315-5761
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-13
Last Update Date:2011-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX21060103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical