Provider Demographics
NPI:1982454831
Name:EDWARDS, LISA (CSC, GCADC-I, MRAS)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:CSC, GCADC-I, MRAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1236 HIGHWAY 299
Mailing Address - Street 2:
Mailing Address - City:WILDWOOD
Mailing Address - State:GA
Mailing Address - Zip Code:30757-4003
Mailing Address - Country:US
Mailing Address - Phone:423-428-0045
Mailing Address - Fax:
Practice Address - Street 1:1236 HIGHWAY 299
Practice Address - Street 2:
Practice Address - City:WILDWOOD
Practice Address - State:GA
Practice Address - Zip Code:30757-4003
Practice Address - Country:US
Practice Address - Phone:423-428-0045
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-25
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAG0095101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)