Provider Demographics
NPI:1760841019
Name:PIERCE, EDWARD RUSSELL
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:RUSSELL
Last Name:PIERCE
Suffix:
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 1:1485 S SEMORAN BLVD
Mailing Address - Street 2:SUITE 1448
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32792-5533
Mailing Address - Country:US
Mailing Address - Phone:321-397-3000
Mailing Address - Fax:
Practice Address - Street 1:20162 CORTEZ BLVD
Practice Address - Street 2:SUITE 1448
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34601-3832
Practice Address - Country:US
Practice Address - Phone:352-544-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-15
Last Update Date:2016-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH 13511101YM0800X
FLIMT 2292106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist