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General NPI Number Information
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NPI Number | 1750697256
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Entity Type | Individual
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Provider Name | EDWARD ALFRED THIRY III LSW, CAC
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Gender | Male
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Dates
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Enumeration Date | 08/23/2010
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Last Update Date | 08/30/2010
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Provider Practice Location Address
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Address Line | 4845 W LAKE RD SUITE 120
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City | ERIE
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State | PA
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Zip | 16505-2973
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Country | US
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Telephone | 814-528-5323
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Fax |
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Provider Business Mailing Address
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Address Line | 4845 W LAKE RD SUITE 120
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City | ERIE
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State | PA
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Zip | 16505-2973
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Country | US
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Telephone | 814-528-5323
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number | SW125058
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License Number State | PA
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Taxonomy #2
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 5918
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License Number State | PA
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