Provider Demographics
NPI:1841536406
Name:GRESHAM, EDWIN ANTOINE (LCSW)
Entity type:Individual
Prefix:
First Name:EDWIN
Middle Name:ANTOINE
Last Name:GRESHAM
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 INDEPENDENCE DRIVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:MS
Mailing Address - Zip Code:39710-5300
Mailing Address - Country:US
Mailing Address - Phone:662-434-2273
Mailing Address - Fax:
Practice Address - Street 1:201 INDEPENDENCE DRIVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:MS
Practice Address - Zip Code:39710-5300
Practice Address - Country:US
Practice Address - Phone:662-434-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-28
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0055841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical