Provider Demographics
NPI:1003138645
Name:EDWARDS, THERESA DIANE (LSW)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:DIANE
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:445 4TH ST
Mailing Address - Street 2:SECOND FLOOR
Mailing Address - City:BRADDOCK
Mailing Address - State:PA
Mailing Address - Zip Code:15104-1463
Mailing Address - Country:US
Mailing Address - Phone:412-583-9681
Mailing Address - Fax:
Practice Address - Street 1:445 4TH ST
Practice Address - Street 2:SECOND FLOOR
Practice Address - City:BRADDOCK
Practice Address - State:PA
Practice Address - Zip Code:15104-1463
Practice Address - Country:US
Practice Address - Phone:412-583-9681
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-24
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASW127377104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1024653590003Medicaid