1801040530 NPI number — CAROL B EDWARDS, PSYD, HSPP, CLINICAL PSYCHOLOGIST, LLC

Table of content: (NPI 1801040530)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801040530 NPI number — CAROL B EDWARDS, PSYD, HSPP, CLINICAL PSYCHOLOGIST, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CAROL B EDWARDS, PSYD, HSPP, CLINICAL PSYCHOLOGIST, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
DR. CAROL EDWARDS
Provider Other Organization Name Type Code:
3
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:
1801040530
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/07/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1156
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VALPARAISO
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46384-1156
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
219-791-1006
Provider Business Mailing Address Fax Number:
219-791-1007

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9111 BROADWAY
Provider Second Line Business Practice Location Address:
SUITE N
Provider Business Practice Location Address City Name:
MERRILLVILLE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46410-8122
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-791-1006
Provider Business Practice Location Address Fax Number:
219-791-1007
Provider Enumeration Date:
11/07/2008

Additional Information

Authorized Official

Authorized Official Last Name:
EDWARDS
Authorized Official First Name:
CAROL
Authorized Official Middle Name:
B
Authorized Official Title or Position:
CLINICAL PSYCHOLOGIST
Authorized Official Telephone Number:
219-791-1006

Provider Taxonomy Codes

  • Taxonomy code: 261QM0801X , with the licence number:  20041414A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 11388127 . This is a "CAQH" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 200337570A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1639142516 . This is a "NPI INDIVIDUAL PROVIDER" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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