Provider Demographics
NPI:1952817462
Name:EDGAR, JOHN (LISW)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:EDGAR
Suffix:
Gender:M
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1106 NORTHWEST BLVD
Mailing Address - Street 2:
Mailing Address - City:GRANDVIEW HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:43212-3631
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5665 HOOVER RD
Practice Address - Street 2:
Practice Address - City:GROVE CITY
Practice Address - State:OH
Practice Address - Zip Code:43123-9122
Practice Address - Country:US
Practice Address - Phone:614-753-6080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-19
Last Update Date:2019-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
I.19018361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical