Provider Demographics
NPI:1679807317
Name:EDGE, LUCRETIA GOLDIZEN (LICSW)
Entity Type:Individual
Prefix:MS
First Name:LUCRETIA
Middle Name:GOLDIZEN
Last Name:EDGE
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:LUANN
Other - Middle Name:
Other - Last Name:EDGE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LICSW
Mailing Address - Street 1:6 PARK STREET
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26847
Mailing Address - Country:US
Mailing Address - Phone:304-257-1155
Mailing Address - Fax:
Practice Address - Street 1:6 PARK ST
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:WV
Practice Address - Zip Code:26847-1765
Practice Address - Country:US
Practice Address - Phone:304-257-1155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-29
Last Update Date:2009-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVDP009428201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical