Provider Demographics
NPI:1538170188
Name:EDWARDS, SCOTT ANDREW (PHD HSPP)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:ANDREW
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:PHD HSPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6181
Mailing Address - Street 2:
Mailing Address - City:KOKOMO
Mailing Address - State:IN
Mailing Address - Zip Code:46904-6181
Mailing Address - Country:US
Mailing Address - Phone:765-854-6010
Mailing Address - Fax:765-854-6011
Practice Address - Street 1:1216 W JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46901-4341
Practice Address - Country:US
Practice Address - Phone:765-854-6010
Practice Address - Fax:765-854-6011
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2010-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20041730A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
064306000OtherMAGELLAN
IN200365990Medicaid
IN000000507244OtherANTHEM
IN000000507244OtherANTHEM