Provider Demographics
NPI:1790936599
Name:FAULKNER, EDWARD RANDALL (LSW)
Entity Type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:RANDALL
Last Name:FAULKNER
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:404 GRASSMERE AVE
Mailing Address - Street 2:
Mailing Address - City:INTERLAKEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07712-4313
Mailing Address - Country:US
Mailing Address - Phone:215-817-7372
Mailing Address - Fax:215-554-6966
Practice Address - Street 1:1985 STATE ROUTE 34 STE A3
Practice Address - Street 2:
Practice Address - City:WALL TOWNSHIP
Practice Address - State:NJ
Practice Address - Zip Code:07719-9101
Practice Address - Country:US
Practice Address - Phone:215-817-7372
Practice Address - Fax:215-554-6966
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-10
Last Update Date:2022-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASW126856104100000X
NJ44SC05919000104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker