Provider Demographics
NPI:1467632513
Name:EDWARDS, LONNIE T
Entity Type:Individual
Prefix:MR
First Name:LONNIE
Middle Name:T
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 N ORANGE ST
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19801-2296
Mailing Address - Country:US
Mailing Address - Phone:302-656-4044
Mailing Address - Fax:302-656-3439
Practice Address - Street 1:625 N ORANGE ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19801-2296
Practice Address - Country:US
Practice Address - Phone:302-656-4044
Practice Address - Fax:302-656-3439
Is Sole Proprietor?:No
Enumeration Date:2007-11-06
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DE103TP2701X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE103TP2701XMedicaid