Provider Demographics
NPI:1588088538
Name:FLYNN, EDWARD
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:
Last Name:FLYNN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4024 WYOMING ST
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63116-3920
Mailing Address - Country:US
Mailing Address - Phone:314-378-0290
Mailing Address - Fax:314-454-5715
Practice Address - Street 1:5261 DELMAR BLVD
Practice Address - Street 2:SUITE 214
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63108-1063
Practice Address - Country:US
Practice Address - Phone:314-497-6617
Practice Address - Fax:314-454-5715
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-11
Last Update Date:2014-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014000915101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health