Provider Demographics
NPI:1821467705
Name:EDWARDS, CLINT
Entity Type:Individual
Prefix:
First Name:CLINT
Middle Name:
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58811 SANTA BARBARA DR
Mailing Address - Street 2:
Mailing Address - City:YUCCA VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92284-6459
Mailing Address - Country:US
Mailing Address - Phone:760-702-6188
Mailing Address - Fax:760-560-5924
Practice Address - Street 1:58811 SANTA BARBARA DR
Practice Address - Street 2:
Practice Address - City:YUCCA VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92284-6459
Practice Address - Country:US
Practice Address - Phone:760-702-6188
Practice Address - Fax:760-560-5924
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-21
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95-2225798101YM0800X
CA1064871041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health