Basic Information
| Provider Information | |||||||||
| NPI: | 1063449114 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BARRETT | ||||||||
| FirstName: | EDWIN | ||||||||
| MiddleName: | T | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 636256 | ||||||||
| Address2: | CENTRAL CREDENTIALING | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45263 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5135855504 | ||||||||
| FaxNumber: | 5135855511 | ||||||||
| Practice Location | |||||||||
| Address1: | 222 PIEDMONT AVE | ||||||||
| Address2: | SUITE 3200 | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5134758730 | ||||||||
| FaxNumber: | 5134758033 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2006 | ||||||||
| LastUpdateDate: | 01/08/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103G00000X | 3045 | OH | Y | Behavioral Health & Social Service Providers | Clinical Neuropsychologist |
ID Information
| ID | Type | State | Issuer | Description | 0611136 | 05 | OH | MEDICAID | 680004445 | 01 | OH | MEDICARE RAILROAD | OTHER |