Healthcare Provider Details

I. General information

NPI: 1962014175
Provider Name (Legal Business Name): CALVIN AUSTIN EDMUNDSON LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2020
Last Update Date: 08/19/2020
Certification Date: 08/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4605 MONTICELLO RD STE 3
COLUMBIA SC
29203-4156
US

IV. Provider business mailing address

169 LAURELHURST AVE
COLUMBIA SC
29210-3825
US

V. Phone/Fax

Practice location:
  • Phone: 803-754-0151
  • Fax: 803-691-1778
Mailing address:
  • Phone: 803-733-5969
  • Fax: 803-753-5591

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number7568
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: