Provider Demographics
NPI:1881607414
Name:EDGEWOOD GROUP FAMILY SERVICES
Entity type:Organization
Organization Name:EDGEWOOD GROUP FAMILY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:TRAVIS
Authorized Official - Last Name:CROCKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-648-0671
Mailing Address - Street 1:4906 FITZHUGH AVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23230-3526
Mailing Address - Country:US
Mailing Address - Phone:804-648-0671
Mailing Address - Fax:804-648-0672
Practice Address - Street 1:4906 FITZHUGH AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23230-3526
Practice Address - Country:US
Practice Address - Phone:804-648-0671
Practice Address - Fax:804-648-0672
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-14
Last Update Date:2011-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA709-05-001101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010127394Medicaid