Provider Demographics
NPI:1720199565
Name:EDWIN, SCOTT I (PHD)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:I
Last Name:EDWIN
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 1:18 SPLIT OAK DR
Mailing Address - Street 2:
Mailing Address - City:EAST NORWICH
Mailing Address - State:NY
Mailing Address - Zip Code:11732-1131
Mailing Address - Country:US
Mailing Address - Phone:516-922-1220
Mailing Address - Fax:
Practice Address - Street 1:18 SPLIT OAK DR
Practice Address - Street 2:
Practice Address - City:EAST NORWICH
Practice Address - State:NY
Practice Address - Zip Code:11732-1131
Practice Address - Country:US
Practice Address - Phone:516-922-1220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006260-1103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical