Provider Demographics
NPI:1912245812
Name:EDWARDS, RICHARD ALLEN (LAC)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:ALLEN
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:T-9 FORT MISSOULA
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59804-7202
Mailing Address - Country:US
Mailing Address - Phone:406-532-8400
Mailing Address - Fax:406-543-9316
Practice Address - Street 1:1467 HAYES DR
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59808-1231
Practice Address - Country:US
Practice Address - Phone:406-532-8952
Practice Address - Fax:406-543-6751
Is Sole Proprietor?:No
Enumeration Date:2013-01-28
Last Update Date:2013-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT2609101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)