Basic Information
| Provider Information | |||||||||
| NPI: | 1184632549 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EDWARDS | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | A. | ||||||||
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| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 607 IDOL ST | ||||||||
| Address2: | |||||||||
| City: | HIGH POINT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272627804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3368022407 | ||||||||
| FaxNumber: | 3368022401 | ||||||||
| Practice Location | |||||||||
| Address1: | 721 N ELM ST | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | HIGH POINT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272623928 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3368022205 | ||||||||
| FaxNumber: | 3368022599 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 23 | NC | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 23 | 01 | NC | LICENSE NUMBER | OTHER | 6000901 | 05 | NC | MEDICAID |