Provider Demographics
NPI:1538307145
Name:EDWARDS, TANYA M (LCSW)
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:M
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:TANYA
Other - Middle Name:MARIE
Other - Last Name:EDWARDS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:501 AVALON WAY
Mailing Address - Street 2:STE D
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39047-7500
Mailing Address - Country:US
Mailing Address - Phone:601-951-9863
Mailing Address - Fax:601-362-4061
Practice Address - Street 1:248 E CAPITOL ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39201-2503
Practice Address - Country:US
Practice Address - Phone:800-632-6074
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-04
Last Update Date:2019-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSC74861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical