Provider Demographics
NPI:1417052127
Name:BLEVINS, EDNA LOUISE (LCSW)
Entity Type:Individual
Prefix:
First Name:EDNA
Middle Name:LOUISE
Last Name:BLEVINS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:EDNA
Other - Middle Name:LOUISE
Other - Last Name:MCCARTHY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 10414
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33773-0414
Mailing Address - Country:US
Mailing Address - Phone:800-632-6074
Mailing Address - Fax:
Practice Address - Street 1:120 PENMARC DR
Practice Address - Street 2:SUITE 118
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27603-2400
Practice Address - Country:US
Practice Address - Phone:800-632-6074
Practice Address - Fax:800-632-6079
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2010-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0010181041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6003263Medicaid
NCP00332196OtherRR MEDICARE WITH PARADIGM
NC6003263Medicaid