Provider Demographics
NPI:1073211751
Name:EDWARDS, ALEXANDER (R1386350420)
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:R1386350420
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:929 S TOWNSEND ST
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92704-2925
Mailing Address - Country:US
Mailing Address - Phone:341-766-4032
Mailing Address - Fax:
Practice Address - Street 1:1207 E FRUIT ST
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92701-4296
Practice Address - Country:US
Practice Address - Phone:341-766-4032
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-21
Last Update Date:2023-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1386350420101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)