Provider Demographics
NPI:1619975000
Name:SOLOMON, EDWARD RUSSELL (LPC, MS)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:RUSSELL
Last Name:SOLOMON
Suffix:
Gender:M
Credentials:LPC, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 N GARTH AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-4103
Mailing Address - Country:US
Mailing Address - Phone:573-449-2581
Mailing Address - Fax:573-449-2583
Practice Address - Street 1:117 N GARTH AVE
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-4103
Practice Address - Country:US
Practice Address - Phone:573-449-2581
Practice Address - Fax:573-449-2583
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO001442101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional