Provider Demographics
NPI:1790275485
Name:EDGE COUNSELING AND WELLNESS LLC
Entity Type:Organization
Organization Name:EDGE COUNSELING AND WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AUDREY
Authorized Official - Middle Name:
Authorized Official - Last Name:LEMASTERS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:309-360-8912
Mailing Address - Street 1:719 W LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-5941
Mailing Address - Country:US
Mailing Address - Phone:309-360-8912
Mailing Address - Fax:
Practice Address - Street 1:719 W LAKE AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-5941
Practice Address - Country:US
Practice Address - Phone:309-360-8912
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-17
Last Update Date:2021-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty