Provider Demographics
NPI:1457375495
Name:EDWARDS, THERESA (PHD)
Entity type:Individual
Prefix:DR
First Name:THERESA
Middle Name:
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 98273
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27624-8273
Mailing Address - Country:US
Mailing Address - Phone:919-845-4550
Mailing Address - Fax:
Practice Address - Street 1:8384 SIX FORKS RD
Practice Address - Street 2:SUITE 104
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27615-5079
Practice Address - Country:US
Practice Address - Phone:919-845-4550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2014-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1532103T00000X, 103TC2200X, 103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCNONEOtherHEALTH SERVICES PROVIDER
NC1532OtherPSYCHOLOGY LICENSE
NC0333AOtherBCBS PROVIDER #
NC6000501Medicaid