MEDICARE: ERICA RENEE EDGE LCSW

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	1041C0700X	Clinical Social Worker	DP00945484	WV
2	1041C0700X	Clinical Social Worker	4316	HI

General Provider Information

NPI Number	:	1790276954
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ERICA RENEE EDGE LCSW

Provider Business Mailing Address
First Line	:	4007 LONG POINT BLVD
Second Line	:
City	:	PORTSMOUTH
State	:	VA
Zip	:	23703-5348
Country	:	US
Telephone Number	:	808-825-1650
Fax Number	:

Provider Business Practice Location Address
First Line	:	4007 LONG POINT BLVD
Second Line	:
City	:	PORTSMOUTH
State	:	VA
Zip	:	23703-5348
Country	:	US
Telephone Number	:	808-825-1650
Fax Number	:

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

Provider Enumeration Date	:	05/23/2018
Last Update Date	:	10/14/2023

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