Provider Demographics
NPI:1578076873
Name:BLAND, EDWARD AVERY
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:AVERY
Last Name:BLAND
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:AVERY
Other - Middle Name:
Other - Last Name:BLAND
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3008 TYLER CT
Mailing Address - Street 2:
Mailing Address - City:INDIAN LAND
Mailing Address - State:SC
Mailing Address - Zip Code:29707-7489
Mailing Address - Country:US
Mailing Address - Phone:864-838-8045
Mailing Address - Fax:
Practice Address - Street 1:2460 INDIA HOOK RD STE AND105
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-3530
Practice Address - Country:US
Practice Address - Phone:803-366-6250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-08
Last Update Date:2017-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician