Healthcare Provider Details

I. General information

NPI: 1518547603
Provider Name (Legal Business Name): DALLAS JAMES EDGE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2021
Last Update Date: 03/25/2026
Certification Date: 03/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1545 HOTEL CIR S STE 300
SAN DIEGO CA
92108-3414
US

IV. Provider business mailing address

1545 HOTEL CIR S STE 300
SAN DIEGO CA
92108-3414
US

V. Phone/Fax

Practice location:
  • Phone: 619-549-0329
  • Fax:
Mailing address:
  • Phone: 619-549-0329
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPCC21772
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberAPCC11789
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: