Provider Demographics
NPI:1982630596
Name:EDWARDS, JR., QUINTON THOMAS (PHD)
Entity Type:Individual
Prefix:DR
First Name:QUINTON
Middle Name:THOMAS
Last Name:EDWARDS, JR.
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 1:707 W UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47303-3865
Mailing Address - Country:US
Mailing Address - Phone:765-254-9343
Mailing Address - Fax:
Practice Address - Street 1:707 W UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47303-3865
Practice Address - Country:US
Practice Address - Phone:765-254-9343
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20041921A103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN20041921AOtherLICENSE #