=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053521617
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EDWARD E TEDROW LCSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/23/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2238 FIRST ST.
-----------------------------------------------------
City | SLIDELL
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70458
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 985-690-6622
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 350 BYRAM DR APT 812
-----------------------------------------------------
City | BYRAM
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39272-9286
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 604-372-5145
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 3887
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------