Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 102L00000X | Psychologist | 1167 | WI |
N | 103T00000X | Psychologist | 1167 | WI |
N | 102L00000X | Psychologist | PY0409 | NV |
N | 103T00000X | Psychologist | PY0409 | NV |
N | 103TA0700X | Adult Development & Aging Psychologist | 1167 | WI |
N | 103TA0700X | Adult Development & Aging Psychologist | PY0409 | NV |
N | 103TB0200X | Cognitive & Behavioral Psychologist | 1167 | WI |
N | 103TB0200X | Cognitive & Behavioral Psychologist | PY0409 | NV |
N | 103TF0200X | Forensic Psychologist | 1167 | WI |
N | 103TF0200X | Forensic Psychologist | PY0409 | NV |
NPI | 1003939356 |
---|---|
Provider Name | Dr. Kenneth Anthony Edwards |
First Address | Dayton, NV 89403-0115 |
Second Address | Mound House, NV 89706 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/04/2007 |
Last Update Date | 08/07/2007 |