Provider Demographics
NPI:1104036664
Name:EDWARDS, KRISTINE RUTH (LPC, PC)
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:RUTH
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:LPC, PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5647 MAYBERRY SQ E
Mailing Address - Street 2:
Mailing Address - City:SYLVANIA
Mailing Address - State:OH
Mailing Address - Zip Code:43560-9456
Mailing Address - Country:US
Mailing Address - Phone:734-755-7136
Mailing Address - Fax:
Practice Address - Street 1:5647 MAYBERRY SQ E
Practice Address - Street 2:
Practice Address - City:SYLVANIA
Practice Address - State:OH
Practice Address - Zip Code:43560-9456
Practice Address - Country:US
Practice Address - Phone:734-755-7136
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2019-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401008894101YP2500X
OHC.0500154101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional