Healthcare Provider Details

I. General information

NPI: 1306739883
Provider Name (Legal Business Name): THEO EDWARDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2025
Last Update Date: 08/28/2026
Certification Date: 08/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N CHESTNUT ST STE 225
CHAMPAIGN IL
61820-3329
US

IV. Provider business mailing address

100 N CHESTNUT ST STE 225
CHAMPAIGN IL
61820-3329
US

V. Phone/Fax

Practice location:
  • Phone: 217-203-2030
  • Fax: 217-355-1255
Mailing address:
  • Phone: 217-203-2030
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: