Healthcare Provider Details

I. General information

NPI: 1881120517
Provider Name (Legal Business Name): GINA EDWARDS, PHD, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2017
Last Update Date: 05/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1679 WILLAMETTE ST
EUGENE OR
97401-4013
US

IV. Provider business mailing address

1679 WILLAMETTE ST
EUGENE OR
97401-4013
US

V. Phone/Fax

Practice location:
  • Phone: 541-525-2332
  • Fax: 541-344-1129
Mailing address:
  • Phone: 541-525-2332
  • Fax: 541-344-1129

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberC4416
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. GINA EDWARDS
Title or Position: LICENSED PROFESSIONAL COUNSELOR
Credential: MA, PHD
Phone: 541-525-2332