Healthcare Provider Details

I. General information

NPI: 1336858919
Provider Name (Legal Business Name): ANDRE EDGARIAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2022
Last Update Date: 11/22/2022
Certification Date: 11/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2008 BREMO RD STE 111
RICHMOND VA
23226-2443
US

IV. Provider business mailing address

199 HILLCREST AVE
LEONIA NJ
07605-1510
US

V. Phone/Fax

Practice location:
  • Phone: 804-918-1115
  • Fax:
Mailing address:
  • Phone: 201-694-7485
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: