Healthcare Provider Details

I. General information

NPI: 1336386655
Provider Name (Legal Business Name): TERRY BERNARD EDWARDS LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2009
Last Update Date: 05/14/2026
Certification Date: 05/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11301 WILSHIRE BLVD
LOS ANGELES CA
90073-1003
US

IV. Provider business mailing address

338 W 35TH ST
SAN PEDRO CA
90731-6896
US

V. Phone/Fax

Practice location:
  • Phone: 818-891-7711
  • Fax:
Mailing address:
  • Phone: 901-605-5128
  • Fax: 213-267-9077

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number2016031084
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLMSW-3841-M
License Number StateAR
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number3841-M
License Number StateAR
# 4
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberSC61625487
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: