Healthcare Provider Details

I. General information

NPI: 1003138645
Provider Name (Legal Business Name): THERESA DIANE EDWARDS LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/24/2010
Last Update Date: 09/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

445 4TH ST SECOND FLOOR
BRADDOCK PA
15104-1463
US

IV. Provider business mailing address

445 4TH ST SECOND FLOOR
BRADDOCK PA
15104-1463
US

V. Phone/Fax

Practice location:
  • Phone: 412-583-9681
  • Fax:
Mailing address:
  • Phone: 412-583-9681
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberSW127377
License Number StatePA

VII. Legacy identifiers

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

# 1
Identifier1024653590003
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: