Provider Demographics
NPI:1841492006
Name:EDWARDS, ALLIE W (PHD)
Entity type:Individual
Prefix:DR
First Name:ALLIE
Middle Name:W
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1970 BROADWAY
Mailing Address - Street 2:SUITE 835
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94612
Mailing Address - Country:US
Mailing Address - Phone:510-409-9238
Mailing Address - Fax:510-727-9761
Practice Address - Street 1:1970 BROADWAY
Practice Address - Street 2:SUITE 835
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94612
Practice Address - Country:US
Practice Address - Phone:510-409-9238
Practice Address - Fax:510-727-9761
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-01
Last Update Date:2015-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 18234103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist