Provider Demographics
NPI:1023328481
Name:DAVIES, EDWINA ANNETTE
Entity type:Individual
Prefix:MRS
First Name:EDWINA
Middle Name:ANNETTE
Last Name:DAVIES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 LOUDOUN RD
Mailing Address - Street 2:
Mailing Address - City:INDIAN TRAIL
Mailing Address - State:NC
Mailing Address - Zip Code:28079-8478
Mailing Address - Country:US
Mailing Address - Phone:310-762-2372
Mailing Address - Fax:
Practice Address - Street 1:1000 LOUDOUN RD
Practice Address - Street 2:
Practice Address - City:INDIAN TRAIL
Practice Address - State:NC
Practice Address - Zip Code:28079-8478
Practice Address - Country:US
Practice Address - Phone:310-762-2372
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-19
Last Update Date:2011-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101073854103TC1900X
NC00026174400000X
NC0005174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No174400000XOther Service ProvidersSpecialist