Provider Demographics
NPI:1508623026
Name:ICAZA GALARZA, EDISON DAVID (LGPC)
Entity Type:Individual
Prefix:
First Name:EDISON
Middle Name:DAVID
Last Name:ICAZA GALARZA
Suffix:
Gender:M
Credentials:LGPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1307 SEVEN LOCKS RD
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20854-2909
Mailing Address - Country:US
Mailing Address - Phone:240-777-9862
Mailing Address - Fax:
Practice Address - Street 1:1307 SEVEN LOCKS RD
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20854-2909
Practice Address - Country:US
Practice Address - Phone:240-777-9862
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-01
Last Update Date:2024-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP14313101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health