Provider Demographics
NPI:1629494463
Name:EDWARD, WILLIE
Entity Type:Individual
Prefix:
First Name:WILLIE
Middle Name:
Last Name:EDWARD
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 1:1701 WHITE ST
Mailing Address - Street 2:
Mailing Address - City:MCCOMB
Mailing Address - State:MS
Mailing Address - Zip Code:39648-2711
Mailing Address - Country:US
Mailing Address - Phone:601-249-4228
Mailing Address - Fax:601-249-4244
Practice Address - Street 1:1701 WHITE ST
Practice Address - Street 2:
Practice Address - City:MCCOMB
Practice Address - State:MS
Practice Address - Zip Code:39648-2711
Practice Address - Country:US
Practice Address - Phone:601-249-4228
Practice Address - Fax:601-249-4244
Is Sole Proprietor?:No
Enumeration Date:2014-03-17
Last Update Date:2014-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS0152101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)