Provider Demographics
NPI:1538282199
Name:KEARNEY, EDMUND M (PHD)
Entity type:Individual
Prefix:DR
First Name:EDMUND
Middle Name:M
Last Name:KEARNEY
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 1:115 S 2ND ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-2812
Mailing Address - Country:US
Mailing Address - Phone:630-377-5797
Mailing Address - Fax:
Practice Address - Street 1:115 S 2ND ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-2812
Practice Address - Country:US
Practice Address - Phone:630-377-5797
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent