Healthcare Provider Details

I. General information

NPI: 1013900687
Provider Name (Legal Business Name): CHARLOTTE ANN EDELEN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/29/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 PURCELL RD SUITE B
POTOSI MO
63664-1455
US

IV. Provider business mailing address

600 PURCELL RD SUITE B
POTOSI MO
63664-1455
US

V. Phone/Fax

Practice location:
  • Phone: 573-438-9355
  • Fax: 573-438-7892
Mailing address:
  • Phone: 573-438-9355
  • Fax: 573-438-7892

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number001877
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: