Provider Demographics
NPI:1922731686
Name:SERVIUS, EDWIN PHILLIP (PHD)
Entity Type:Individual
Prefix:DR
First Name:EDWIN
Middle Name:PHILLIP
Last Name:SERVIUS
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 1:693 NW 133RD WAY
Mailing Address - Street 2:
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33325-6152
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10645 NW 7TH AVE STE 103
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33150-1067
Practice Address - Country:US
Practice Address - Phone:305-751-8373
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-08
Last Update Date:2022-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLE5801006103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst