Provider Demographics
NPI:1457340952
Name:REISFELD, EDWIN H (PHD)
Entity Type:Individual
Prefix:DR
First Name:EDWIN
Middle Name:H
Last Name:REISFELD
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 1:52511 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:704-944-3201
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
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-18
Last Update Date:2011-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3748103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2826004AOtherMEDICARE INDIVIDUAL PTAN
NC2826004OtherMEDICARE PTAN