Provider Demographics
NPI:1457345266
Name:JOSEPH, EDWIN DEJ PERRY III (PHD)
Entity Type:Individual
Prefix:DR
First Name:EDWIN
Middle Name:DEJ PERRY
Last Name:JOSEPH
Suffix:III
Gender:M
Credentials:PHD
Other - Prefix:DR
Other - First Name:EDWIN
Other - Middle Name:J I
Other - Last Name:FERACO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:PO BOX 521
Mailing Address - Street 2:
Mailing Address - City:OLD MYSTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06372-0521
Mailing Address - Country:US
Mailing Address - Phone:860-415-6837
Mailing Address - Fax:
Practice Address - Street 1:44 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:MYSTIC
Practice Address - State:CT
Practice Address - Zip Code:06355-2839
Practice Address - Country:US
Practice Address - Phone:860-415-6837
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-07
Last Update Date:2014-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0041441041C0700X
103TC1900X
RIISW014911041C0700X
AK3714101YA0400X
CT46.002377101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTS43346Medicare UPIN
CT800002462Medicare ID - Type Unspecified