Provider Demographics
NPI:1033772496
Name:EDWARDS, DOUGLAS (CSAC 24173)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:CSAC 24173
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 DOUGLAS ST
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28312-5310
Mailing Address - Country:US
Mailing Address - Phone:910-682-8872
Mailing Address - Fax:
Practice Address - Street 1:118 DOUGLAS ST
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28312-5310
Practice Address - Country:US
Practice Address - Phone:910-682-8872
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-20
Last Update Date:2019-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC24173101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)