Provider Demographics
NPI:1821583972
Name:EDWARDS, DARNELL LARRY (CDCA)
Entity Type:Individual
Prefix:
First Name:DARNELL
Middle Name:LARRY
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 SPINK ST
Mailing Address - Street 2:
Mailing Address - City:WOOSTER
Mailing Address - State:OH
Mailing Address - Zip Code:44691-3652
Mailing Address - Country:US
Mailing Address - Phone:330-264-8498
Mailing Address - Fax:330-264-3777
Practice Address - Street 1:245 BEALL AVE
Practice Address - Street 2:
Practice Address - City:WOOSTER
Practice Address - State:OH
Practice Address - Zip Code:44691-3674
Practice Address - Country:US
Practice Address - Phone:330-262-6903
Practice Address - Fax:330-264-0646
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-29
Last Update Date:2018-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH161386101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH161386Medicaid
OH161386OtherSUD COUNSELOR
OH161386OtherSUD COUNSELOR