Basic Information
| Provider Information | |||||||||
| NPI: | 1679892103 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEW | ||||||||
| FirstName: | EDGAR | ||||||||
| MiddleName: | J. | ||||||||
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| Credential: | L.P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1825 MARIKA RD | ||||||||
| Address2: | |||||||||
| City: | FAIRBANKS | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997095521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074740890 | ||||||||
| FaxNumber: | 9074518945 | ||||||||
| Practice Location | |||||||||
| Address1: | 1825 MARIKA RD | ||||||||
| Address2: | |||||||||
| City: | FAIRBANKS | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997095521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074740890 | ||||||||
| FaxNumber: | 9074518945 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2010 | ||||||||
| LastUpdateDate: | 10/16/2012 | ||||||||
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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 | 101YP2500X | 6401009081 | MI | N | Behavioral Health & Social Service Providers | Counselor | Professional | 101YP2500X | 705 | AK | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.