Provider Demographics
NPI:1700206489
Name:EDWARDS, LIESL (PHD)
Entity Type:Individual
Prefix:
First Name:LIESL
Middle Name:
Last Name:EDWARDS
Suffix:
Gender:F
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:PSC 44 BOX 225
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09464-0003
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:RAF LAKENHEATH 48 MDG/SGHC
Practice Address - Street 2:UNIT 5115
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09461-5115
Practice Address - Country:US
Practice Address - Phone:314-226-3308
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-22
Last Update Date:2018-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX70191103TS0200X
KS2758655713103TS0200X
KS2199103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool