Healthcare Provider Details

I. General information

NPI: 1114201944
Provider Name (Legal Business Name): T EDWARDS AND ASSOCIATES, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2011
Last Update Date: 09/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8394 SIX FORKS RD STE 104
RALEIGH NC
27615-3057
US

IV. Provider business mailing address

PO BOX 98273
RALEIGH NC
27624-8273
US

V. Phone/Fax

Practice location:
  • Phone: 919-845-4550
  • Fax: 919-845-2922
Mailing address:
  • Phone: 919-845-4550
  • Fax: 919-845-2922

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number1532
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number1532
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number1532
License Number StateNC
# 4
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number1532
License Number StateNC

VIII. Authorized Official

Name: THERESA EDWARDS
Title or Position: OWNER
Credential: PHD
Phone: 919-845-4550