Provider Demographics
NPI:1346630530
Name:EDWARDS, MARY LOUISE (MED LPCA)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:LOUISE
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:MED LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6133 SUTTER LOOP E
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42303-9747
Mailing Address - Country:US
Mailing Address - Phone:270-281-9076
Mailing Address - Fax:
Practice Address - Street 1:6133 SUTTER LOOP EAST
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303
Practice Address - Country:US
Practice Address - Phone:270-281-9076
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-27
Last Update Date:2015-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYLPCCA00216556101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYLPCCCA00216556Medicaid