Provider Demographics
NPI:1184895062
Name:EDWARDS, ETHEL L (LMFT, LMSW)
Entity type:Individual
Prefix:MS
First Name:ETHEL
Middle Name:L
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:LMFT, LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 460429
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78246-0429
Mailing Address - Country:US
Mailing Address - Phone:210-446-8255
Mailing Address - Fax:888-823-3497
Practice Address - Street 1:7300 BLANCO RD
Practice Address - Street 2:SUITE 501
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78216-4936
Practice Address - Country:US
Practice Address - Phone:210-446-8255
Practice Address - Fax:888-823-3497
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-18
Last Update Date:2016-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4046106H00000X
TX06246104100000X
TX281101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX71110303Medicaid