Provider Demographics
NPI:1881719698
Name:EDWARDS, ELIZABETH PRUDEN (ACSW,LCSW,LCAS,CSI)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:PRUDEN
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:ACSW,LCSW,LCAS,CSI
Other - Prefix:
Other - First Name:LINDY
Other - Middle Name:WARMACK
Other - Last Name:KITCHIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PLCSW
Mailing Address - Street 1:PO BOX 475
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:NC
Mailing Address - Zip Code:27845-0475
Mailing Address - Country:US
Mailing Address - Phone:252-535-1070
Mailing Address - Fax:252-535-1090
Practice Address - Street 1:321 HWY. 125
Practice Address - Street 2:
Practice Address - City:ROANOKE RAPIDS
Practice Address - State:NC
Practice Address - Zip Code:27870-6445
Practice Address - Country:US
Practice Address - Phone:252-535-1070
Practice Address - Fax:252-535-1090
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6005473Medicaid
NC6002731Medicaid
NC8301195Medicaid
NC8300131Medicaid