Provider Demographics
NPI:1194019299
Name:EDWARDS, ROSHONNA L (LCSW)
Entity Type:Individual
Prefix:
First Name:ROSHONNA
Middle Name:L
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:ROSHONNA
Other - Middle Name:L
Other - Last Name:PRINCE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:103 RIDGECREST DR
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:MS
Mailing Address - Zip Code:39455-2159
Mailing Address - Country:US
Mailing Address - Phone:601-796-9240
Mailing Address - Fax:
Practice Address - Street 1:103 RIDGECREST DR
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:MS
Practice Address - Zip Code:39455-2159
Practice Address - Country:US
Practice Address - Phone:601-796-9240
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-06
Last Update Date:2013-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSC43131041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS302I803329Medicare PIN