Basic Information
| Provider Information | |||||||||
| NPI: | 1003004854 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WINTER | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | MA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 304 CIRCLE ST | ||||||||
| Address2: | |||||||||
| City: | BECKLEY | ||||||||
| State: | WV | ||||||||
| PostalCode: | 258013212 | ||||||||
| CountryCode: | US | ||||||||
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| 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 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TS0200X | 21009 | WV | Y | Behavioral Health & Social Service Providers | Psychologist | School |
No ID Information.