Provider Demographics
NPI:1164694410
Name:EDWARDS, CORNELIUS (LCADC)
Entity Type:Individual
Prefix:MR
First Name:CORNELIUS
Middle Name:
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:LCADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4895 EDMONDSON CREEK RD
Mailing Address - Street 2:
Mailing Address - City:PRESTON
Mailing Address - State:MD
Mailing Address - Zip Code:21655-1474
Mailing Address - Country:US
Mailing Address - Phone:410-924-9659
Mailing Address - Fax:
Practice Address - Street 1:10 S HANSON ST
Practice Address - Street 2:
Practice Address - City:EASTON
Practice Address - State:MD
Practice Address - Zip Code:21601-3010
Practice Address - Country:US
Practice Address - Phone:410-819-5661
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-27
Last Update Date:2013-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLCA200101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)