Provider Demographics
NPI:1659628030
Name:EDWARDS, GENE RANDOLPH (PHD)
Entity Type:Individual
Prefix:DR
First Name:GENE
Middle Name:RANDOLPH
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1923 J N PEASE PL
Mailing Address - Street 2:SUITE 204
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28262-4513
Mailing Address - Country:US
Mailing Address - Phone:704-503-3535
Mailing Address - Fax:704-593-5555
Practice Address - Street 1:1923 J N PEASE PL
Practice Address - Street 2:SUITE 204
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-4513
Practice Address - Country:US
Practice Address - Phone:704-503-3535
Practice Address - Fax:704-593-5555
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-05
Last Update Date:2012-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3660103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3660OtherNC PSYCHOLOGY BOARD LICENSE NUMBER