Provider Demographics
NPI:1982370698
Name:EDWARDS, LAUREN
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9256 TARA DR SW
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:GA
Mailing Address - Zip Code:30014-2088
Mailing Address - Country:US
Mailing Address - Phone:618-960-6223
Mailing Address - Fax:
Practice Address - Street 1:9256 TARA DR SW
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:GA
Practice Address - Zip Code:30014-2088
Practice Address - Country:US
Practice Address - Phone:618-960-6223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-22
Last Update Date:2021-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARBT-21-170266106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician