Provider Demographics
NPI:1164861787
Name:EDWARDS, ANDREA DENESE
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:DENESE
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12661 NS 3660
Mailing Address - Street 2:
Mailing Address - City:WEWOKA
Mailing Address - State:OK
Mailing Address - Zip Code:74884-6022
Mailing Address - Country:US
Mailing Address - Phone:405-380-7751
Mailing Address - Fax:
Practice Address - Street 1:12661 NS 3660
Practice Address - Street 2:
Practice Address - City:WEWOKA
Practice Address - State:OK
Practice Address - Zip Code:74884-6022
Practice Address - Country:US
Practice Address - Phone:405-380-7751
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-17
Last Update Date:2013-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200287120AMedicaid