Provider Demographics
NPI:1083748537
Name:EDWARDS, WESTON MICHAEL (PHD, LP)
Entity Type:Individual
Prefix:DR
First Name:WESTON
Middle Name:MICHAEL
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:PHD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1409 WILLOW ST STE 400
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55403-3251
Mailing Address - Country:US
Mailing Address - Phone:612-872-1500
Mailing Address - Fax:612-872-2205
Practice Address - Street 1:1409 WILLOW ST STE 400
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55403-3251
Practice Address - Country:US
Practice Address - Phone:612-872-1500
Practice Address - Fax:612-872-2205
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2009-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3347103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
6177516OtherUBH
635K4EDOtherBCBS