Provider Demographics
NPI:1841545357
Name:EDGAR, ANDREA BLAIR (LCSW)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:BLAIR
Last Name:EDGAR
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2845 FREDERICK ST
Mailing Address - Street 2:
Mailing Address - City:CANTONMENT
Mailing Address - State:FL
Mailing Address - Zip Code:32533-5734
Mailing Address - Country:US
Mailing Address - Phone:850-418-1440
Mailing Address - Fax:
Practice Address - Street 1:2845 FREDERICK ST
Practice Address - Street 2:
Practice Address - City:CANTONMENT
Practice Address - State:FL
Practice Address - Zip Code:32533-5734
Practice Address - Country:US
Practice Address - Phone:850-418-1440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-20
Last Update Date:2012-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical