Provider Demographics
NPI:1760666473
Name:EDGE, ELIZABETH L (LMSW)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:L
Last Name:EDGE
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:755 PARK DR NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30306-3681
Mailing Address - Country:US
Mailing Address - Phone:404-374-8630
Mailing Address - Fax:
Practice Address - Street 1:1945 MASON MILL RD STE 100
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-4006
Practice Address - Country:US
Practice Address - Phone:404-374-8630
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-18
Last Update Date:2007-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMSW003466104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker