Provider Demographics
NPI:1205102084
Name:CLEWELL, EDWARD
Entity type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:
Last Name:CLEWELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:TED
Other - Middle Name:
Other - Last Name:CLEWELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2108 MONROE AVE
Mailing Address - Street 2:
Mailing Address - City:ALVA
Mailing Address - State:FL
Mailing Address - Zip Code:33920-1421
Mailing Address - Country:US
Mailing Address - Phone:239-850-8632
Mailing Address - Fax:239-369-3392
Practice Address - Street 1:615 AVENUE O SW
Practice Address - Street 2:
Practice Address - City:MOORE HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33471-2010
Practice Address - Country:US
Practice Address - Phone:863-265-0665
Practice Address - Fax:863-946-1257
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-27
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW5299104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker