Provider Demographics
NPI:1790289973
Name:MCCRICKARD, EDWIN SAMUEL JR
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:SAMUEL
Last Name:MCCRICKARD
Suffix:JR
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 1:1613 HAWTHORNE DR
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23325-3847
Mailing Address - Country:US
Mailing Address - Phone:757-803-5810
Mailing Address - Fax:757-852-4532
Practice Address - Street 1:1613 HAWTHORNE DR
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23325-3847
Practice Address - Country:US
Practice Address - Phone:757-803-5810
Practice Address - Fax:757-631-4767
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-21
Last Update Date:2018-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0813000045103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool