Provider Demographics
NPI:1790519650
Name:EDWARDS, LANDRIA DELESHA
Entity type:Individual
Prefix:
First Name:LANDRIA
Middle Name:DELESHA
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 1:4003 BURR OAK PL
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23435-3364
Mailing Address - Country:US
Mailing Address - Phone:757-537-2337
Mailing Address - Fax:
Practice Address - Street 1:7025 HARBOUR VIEW BLVD STE 119
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23435-2762
Practice Address - Country:US
Practice Address - Phone:757-758-5106
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-31
Last Update Date:2024-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701013936101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional