Provider Demographics
NPI:1659669380
Name:HUNTLEY, EDWARD DEWITT IV
Entity Type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:DEWITT
Last Name:HUNTLEY
Suffix:IV
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1681 FULMER ST
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48103-2452
Mailing Address - Country:US
Mailing Address - Phone:301-655-1936
Mailing Address - Fax:
Practice Address - Street 1:1681 FULMER ST
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48103-2452
Practice Address - Country:US
Practice Address - Phone:301-655-1936
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-15
Last Update Date:2020-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301015379103TB0200X, 103TC2200X, 103TC0700X
6301015379173F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No173F00000XOther Service ProvidersSleep Specialist, PhD