MEDICARE: CLINT EDWARDS

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	101YM0800X	Mental Health Counselor	95-2225798	CA
2	1041C0700X	Clinical Social Worker	106487	CA

General Provider Information

NPI Number	:	1821467705
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CLINT EDWARDS

Provider Business Mailing Address
First Line	:	58811 SANTA BARBARA DR
Second Line	:
City	:	YUCCA VALLEY
State	:	CA
Zip	:	92284-6459
Country	:	US
Telephone Number	:	760-702-6188
Fax Number	:	760-560-5924

Provider Business Practice Location Address
First Line	:	58811 SANTA BARBARA DR
Second Line	:
City	:	YUCCA VALLEY
State	:	CA
Zip	:	92284-6459
Country	:	US
Telephone Number	:	760-702-6188
Fax Number	:	760-560-5924

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

Provider Enumeration Date	:	09/21/2015
Last Update Date	:	05/09/2023

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Directions to “ CLINT EDWARDS ” Practice Location

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