Provider Demographics
NPI:1356173785
Name:EDWARDS, DARRELL DELMAR I (SAC-IT)
Entity type:Individual
Prefix:MR
First Name:DARRELL
Middle Name:DELMAR
Last Name:EDWARDS
Suffix:I
Gender:M
Credentials:SAC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3789 N 75TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53216-1969
Mailing Address - Country:US
Mailing Address - Phone:262-422-9225
Mailing Address - Fax:
Practice Address - Street 1:3707 N RICHARDS ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53212-1673
Practice Address - Country:US
Practice Address - Phone:414-967-7006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-15
Last Update Date:2024-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI20640-130101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)