Provider Demographics
NPI:1760503080
Name:EDWARDS, JOHN A (PHD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:A
Last Name:EDWARDS
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:PO BOX 139
Mailing Address - Street 2:
Mailing Address - City:MACHIAS
Mailing Address - State:ME
Mailing Address - Zip Code:04654-0139
Mailing Address - Country:US
Mailing Address - Phone:207-255-0996
Mailing Address - Fax:
Practice Address - Street 1:294 EAST KENNEBEC ROAD
Practice Address - Street 2:
Practice Address - City:MACHIAS
Practice Address - State:ME
Practice Address - Zip Code:04654
Practice Address - Country:US
Practice Address - Phone:207-255-4990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPS462103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEMM3918Medicare ID - Type UnspecifiedMEDICARE INDIVIDUAL #