Provider Demographics
NPI:1083742134
Name:EDGEWORTH, MYRA KAY (LCSW)
Entity Type:Individual
Prefix:MS
First Name:MYRA
Middle Name:KAY
Last Name:EDGEWORTH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1056 OLD STATE ROUTE 34
Mailing Address - Street 2:
Mailing Address - City:JONESBOROUGH
Mailing Address - State:TN
Mailing Address - Zip Code:37659-6308
Mailing Address - Country:US
Mailing Address - Phone:423-753-7069
Mailing Address - Fax:
Practice Address - Street 1:109 WEST WATAUGA AVENUE
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604
Practice Address - Country:US
Practice Address - Phone:423-979-7474
Practice Address - Fax:423-232-2789
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4492104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker