Provider Demographics
NPI:1659381812
Name:EDWARDS, PHYLLIS JEAN (LPC)
Entity Type:Individual
Prefix:MISS
First Name:PHYLLIS
Middle Name:JEAN
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:804 S. CHOCKTAW
Mailing Address - Street 2:
Mailing Address - City:CHICKASHA
Mailing Address - State:OK
Mailing Address - Zip Code:73018
Mailing Address - Country:US
Mailing Address - Phone:405-222-0622
Mailing Address - Fax:405-224-9532
Practice Address - Street 1:804 S. CHOCKTAW AVE.
Practice Address - Street 2:
Practice Address - City:CHICKASHA
Practice Address - State:OK
Practice Address - Zip Code:73018
Practice Address - Country:US
Practice Address - Phone:405-222-0622
Practice Address - Fax:405-224-9532
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3600101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional