MEDICARE: TERRY BERNARD EDWARDS LMSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	104100000X	Social Worker	2016031084	MO
2	106S00000X	Behavior Technician
3	104100000X	Social Worker	3841-M	AR

General Provider Information

NPI Number	:	1336386655
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TERRY BERNARD EDWARDS LMSW

Provider Business Mailing Address
First Line	:	255 W 5TH ST APT 122
Second Line	:
City	:	SAN PEDRO
State	:	CA
Zip	:	90731-3389
Country	:	US
Telephone Number	:	901-605-5128
Fax Number	:	213-267-9077

Provider Business Practice Location Address
First Line	:	5834 ADENMOOR AVE
Second Line	:
City	:	LAKEWOOD
State	:	CA
Zip	:	90713-1002
Country	:	US
Telephone Number	:	303-989-8169
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/08/2009
Last Update Date	:	09/30/2020

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