MEDICARE: KELLY EDWARDS CDCA

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	171M00000X	Case Manager/Care Coordinator		OH
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	CDCA.188255	OH

General Provider Information

NPI Number	:	1619742426
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY EDWARDS CDCA

Provider Business Mailing Address
First Line	:	10 N WEST AVE
Second Line	:
City	:	WILLARD
State	:	OH
Zip	:	44890-9137
Country	:	US
Telephone Number	:	419-964-3918
Fax Number	:

Provider Business Practice Location Address
First Line	:	125 S MAIN ST
Second Line	:
City	:	FOSTORIA
State	:	OH
Zip	:	44830-2324
Country	:	US
Telephone Number	:	567-429-1000
Fax Number	:

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

Provider Enumeration Date	:	11/21/2023
Last Update Date	:	05/12/2026

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Directions to “ KELLY EDWARDS CDCA” Practice Location

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