Provider Demographics
NPI:1376108191
Name:EDWARDS, CLINTON JAMIE (MA, MED, LCAS, CSI)
Entity Type:Individual
Prefix:MR
First Name:CLINTON
Middle Name:JAMIE
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:MA, MED, LCAS, CSI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6776 SNAKE CREEK RD
Mailing Address - Street 2:
Mailing Address - City:HILLSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24343-4586
Mailing Address - Country:US
Mailing Address - Phone:276-728-6703
Mailing Address - Fax:
Practice Address - Street 1:1151 W LEBANON ST STE 200
Practice Address - Street 2:
Practice Address - City:MOUNT AIRY
Practice Address - State:NC
Practice Address - Zip Code:27030-2225
Practice Address - Country:US
Practice Address - Phone:276-728-6703
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-07
Last Update Date:2022-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS-2133101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)