Provider Demographics
NPI:1629782339
Name:JOHN RODERICK EDWARDS, A LICENSED CLINICAL SOCIAL WORKER CORPORATION
Entity Type:Organization
Organization Name:JOHN RODERICK EDWARDS, A LICENSED CLINICAL SOCIAL WORKER CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:RODERICK
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:510-213-9284
Mailing Address - Street 1:PO BOX 491
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94604-0491
Mailing Address - Country:US
Mailing Address - Phone:510-213-9284
Mailing Address - Fax:510-285-6457
Practice Address - Street 1:2939 SUMMIT ST STE 203
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-3404
Practice Address - Country:US
Practice Address - Phone:510-213-9284
Practice Address - Fax:510-285-6457
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-09
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health