Provider Demographics
NPI:1487681938
Name:EDWARDS, CHARLOTTE D (PSYD)
Entity Type:Individual
Prefix:MRS
First Name:CHARLOTTE
Middle Name:D
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31480 HIGHWAY 45
Mailing Address - Street 2:
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048
Mailing Address - Country:US
Mailing Address - Phone:847-680-2715
Mailing Address - Fax:847-680-3832
Practice Address - Street 1:31480 N US HIGHWAY 45
Practice Address - Street 2:
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-9444
Practice Address - Country:US
Practice Address - Phone:847-680-2715
Practice Address - Fax:847-680-3832
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2014-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071004889103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL392250Medicare ID - Type Unspecified