Healthcare Provider Details

I. General information

NPI: 1396280574
Provider Name (Legal Business Name): LISETTE CAROLA EDWARDS LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/27/2016
Last Update Date: 04/13/2020
Certification Date: 04/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12300 WASHINGTON HWY
ASHLAND VA
23005-7646
US

IV. Provider business mailing address

12300 WASHINGTON HWY
ASHLAND VA
23005-7646
US

V. Phone/Fax

Practice location:
  • Phone: 804-365-4222
  • Fax:
Mailing address:
  • Phone: 804-365-4222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberPCCI 3567
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number07010008955
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: