Healthcare Provider Details

I. General information

NPI: 1750697256
Provider Name (Legal Business Name): EDWARD ALFRED THIRY III LSW, CAC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/23/2010
Last Update Date: 08/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4845 W LAKE RD SUITE 120
ERIE PA
16505-2973
US

IV. Provider business mailing address

4845 W LAKE RD SUITE 120
ERIE PA
16505-2973
US

V. Phone/Fax

Practice location:
  • Phone: 814-528-5323
  • Fax:
Mailing address:
  • Phone: 814-528-5323
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number5918
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberSW125058
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: