1154558526 NPI number — MS. BRENDA J EDWARDS LPC

Table of content: MS. BRENDA J EDWARDS LPC (NPI 1154558526)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154558526 NPI number — MS. BRENDA J EDWARDS LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EDWARDS
Provider First Name:
BRENDA
Provider Middle Name:
J
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1154558526
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/12/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1882 PRINCETON AVE
Provider Second Line Business Mailing Address:
SUITE 9
Provider Business Mailing Address City Name:
COLLEGE PARK
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30337-3537
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-964-6541
Provider Business Mailing Address Fax Number:
888-811-6764

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1882 PRINCETON AVE
Provider Second Line Business Practice Location Address:
SUITE 9
Provider Business Practice Location Address City Name:
COLLEGE PARK
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30337-3537
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-964-6541
Provider Business Practice Location Address Fax Number:
888-811-6764
Provider Enumeration Date:
06/12/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  203335 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YM0800X , with the licence number: LPC005536 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YP2500X , with the licence number: LPC005536 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 882686878A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".