Healthcare Provider Details

I. General information

NPI: 1811352677
Provider Name (Legal Business Name): EDWARD BLEVINS LPC, LCADC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/22/2015
Last Update Date: 09/03/2024
Certification Date: 09/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 MAIN ST REAR SUITE
SPARTA NJ
07871-1937
US

IV. Provider business mailing address

25 MAIN ST REAR SUITE
SPARTA NJ
07871-1937
US

V. Phone/Fax

Practice location:
  • Phone: 908-246-0553
  • Fax:
Mailing address:
  • Phone: 908-246-0553
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number37LC00254100
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number37PC00516900
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: