Provider Demographics
NPI:1902010804
Name:EDWIN REISFELD PHD PA
Entity Type:Organization
Organization Name:EDWIN REISFELD PHD PA
Other - Org Name:EASTSIDE COUNSELING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWIN
Authorized Official - Middle Name:H
Authorized Official - Last Name:REISFELD
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:704-927-5881
Mailing Address - Street 1:52511 WINCHESTER STREET
Mailing Address - Street 2:
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29707
Mailing Address - Country:US
Mailing Address - Phone:704-927-5881
Mailing Address - Fax:
Practice Address - Street 1:15720 JOHN J DELANEY DR
Practice Address - Street 2:SUITE 300
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-3430
Practice Address - Country:US
Practice Address - Phone:704-927-5881
Practice Address - Fax:704-944-3201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-09
Last Update Date:2011-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3748103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2826004OtherMEDICARE PTAN
NC2826004AOtherMEDICARE INDIVIDUAL