Provider Demographics
NPI:1801040530
Name:CAROL B EDWARDS, PSYD, HSPP, CLINICAL PSYCHOLOGIST, LLC
Entity Type:Organization
Organization Name:CAROL B EDWARDS, PSYD, HSPP, CLINICAL PSYCHOLOGIST, LLC
Other - Org Name:DR. CAROL EDWARDS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:B
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD HSPP
Authorized Official - Phone:219-791-1006
Mailing Address - Street 1:PO BOX 1156
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46384-1156
Mailing Address - Country:US
Mailing Address - Phone:219-791-1006
Mailing Address - Fax:219-791-1007
Practice Address - Street 1:9111 BROADWAY
Practice Address - Street 2:SUITE N
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-8122
Practice Address - Country:US
Practice Address - Phone:219-791-1006
Practice Address - Fax:219-791-1007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-07
Last Update Date:2008-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20041414A261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN11388127OtherCAQH
IN200337570AMedicaid
IN1639142516OtherNPI INDIVIDUAL PROVIDER
IN11388127OtherCAQH