Provider Demographics
NPI:1649801788
Name:DILLON, EDWARD SR
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:
Last Name:DILLON
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 E MINNESOTA ST
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:39601-3833
Mailing Address - Country:US
Mailing Address - Phone:601-754-7106
Mailing Address - Fax:
Practice Address - Street 1:225 E MINNESOTA ST
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:MS
Practice Address - Zip Code:39601-3833
Practice Address - Country:US
Practice Address - Phone:601-754-7106
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-28
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSED716381D101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral