Basic Information
Provider Information
NPI: 1003004854
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: WINTER
FirstName: EDWARD
MiddleName: LEE
NamePrefix:  
NameSuffix:  
Credential: MA
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 304 CIRCLE ST
Address2:  
City: BECKLEY
State: WV
PostalCode: 258013212
CountryCode: US
TelephoneNumber:  
FaxNumber:  
Practice Location
Address1: 111 FAYETTE AVE.
Address2: FAYETTE COUNTY SCHOOLS
City: FAYETTEVILLE
State: WV
PostalCode: 25840
CountryCode: US
TelephoneNumber: 3045741176
FaxNumber: 3045743643
Other Information
ProviderEnumerationDate: 10/05/2007
LastUpdateDate: 10/05/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
103TS0200X21009WVY Behavioral Health & Social Service ProvidersPsychologistSchool

No ID Information.


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