Provider Demographics
NPI:1437340130
Name:EDGE, TAMMY E (LPC, EDS)
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:E
Last Name:EDGE
Suffix:
Gender:F
Credentials:LPC, EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 HILLCREST PKWY # 227
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:GA
Mailing Address - Zip Code:31021-3562
Mailing Address - Country:US
Mailing Address - Phone:478-290-5148
Mailing Address - Fax:478-272-8181
Practice Address - Street 1:306 ACADEMY AVE STE 206
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:GA
Practice Address - Zip Code:31021-5286
Practice Address - Country:US
Practice Address - Phone:478-216-6708
Practice Address - Fax:478-272-8181
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-07
Last Update Date:2016-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004884101YP2500X
GA454690103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003169803AMedicaid