Provider Demographics
NPI:1336997501
Name:EDWARDS, CLARISSA
Entity Type:Individual
Prefix:
First Name:CLARISSA
Middle Name:
Last Name:EDWARDS
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 1:3525 WOODRIDGE BLVD APT 9
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45014-7519
Mailing Address - Country:US
Mailing Address - Phone:513-479-7863
Mailing Address - Fax:
Practice Address - Street 1:3525 WOODRIDGE BLVD APT 9
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:OH
Practice Address - Zip Code:45014-7519
Practice Address - Country:US
Practice Address - Phone:513-479-7863
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-10
Last Update Date:2024-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.20054941041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical