Provider Demographics
NPI:1114201944
Name:T EDWARDS AND ASSOCIATES, PLLC
Entity Type:Organization
Organization Name:T EDWARDS AND ASSOCIATES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:919-845-4550
Mailing Address - Street 1:PO BOX 98273
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27624-8273
Mailing Address - Country:US
Mailing Address - Phone:919-845-4550
Mailing Address - Fax:919-845-2922
Practice Address - Street 1:8394 SIX FORKS RD
Practice Address - Street 2:STE 104
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27615-3057
Practice Address - Country:US
Practice Address - Phone:919-845-4550
Practice Address - Fax:919-845-2922
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-28
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1532103T00000X, 103TC2200X, 103TF0000X, 103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Single Specialty
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamilyGroup - Single Specialty
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchoolGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6000501Medicaid
NC1532OtherLICENSE #