Provider Demographics
NPI:1376664359
Name:EDWARDS, MICHAEL (MA, LCPC, LAC)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:MA, LCPC, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2004 HOSPITAL WAY
Mailing Address - Street 2:
Mailing Address - City:WHITEFISH
Mailing Address - State:MT
Mailing Address - Zip Code:59937-7858
Mailing Address - Country:US
Mailing Address - Phone:406-862-1030
Mailing Address - Fax:
Practice Address - Street 1:2004 HOSPITAL WAY
Practice Address - Street 2:
Practice Address - City:WHITEFISH
Practice Address - State:MT
Practice Address - Zip Code:59937-7858
Practice Address - Country:US
Practice Address - Phone:406-862-1030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2016-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-LCPC-LIC-13148101YM0800X
MTBBH-LAC-LIC-13219101YA0400X
NH736101YM0800X
NH650101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
77066380NH01OtherANTHEM