Provider Demographics
NPI:1336386655
Name:EDWARDS, TERRY BERNARD (LMSW)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:BERNARD
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 W 5TH ST APT 122
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90731-3389
Mailing Address - Country:US
Mailing Address - Phone:901-605-5128
Mailing Address - Fax:213-267-9077
Practice Address - Street 1:5834 ADENMOOR AVE
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90713-1002
Practice Address - Country:US
Practice Address - Phone:303-989-8169
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-08
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016031084104100000X
106S00000X
AR3841-M104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician