Provider Demographics
NPI:1437684685
Name:NOREEN EDWARDS EXPRESSIVE ARTS, LICENSED CLINICAL SOCIAL WORKER
Entity Type:Organization
Organization Name:NOREEN EDWARDS EXPRESSIVE ARTS, LICENSED CLINICAL SOCIAL WORKER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:NOREEN
Authorized Official - Middle Name:L
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:707-725-6939
Mailing Address - Street 1:1100 MAIN ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:FORTUNA
Mailing Address - State:CA
Mailing Address - Zip Code:95540-2150
Mailing Address - Country:US
Mailing Address - Phone:707-725-6939
Mailing Address - Fax:707-442-0239
Practice Address - Street 1:1100 MAIN ST
Practice Address - Street 2:SUITE B
Practice Address - City:FORTUNA
Practice Address - State:CA
Practice Address - Zip Code:95540-2150
Practice Address - Country:US
Practice Address - Phone:707-725-6939
Practice Address - Fax:707-442-0239
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-25
Last Update Date:2017-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCSW696651041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACA186598Medicare PIN