Basic Information
| Provider Information | |||||||||
| NPI: | 1679945919 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EDWARDS | ||||||||
| FirstName: | TEONA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 223 FERNWOOD DRIVE SUITE A | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 70806 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2259233733 | ||||||||
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| Practice Location | |||||||||
| Address1: | 223 FERNWOOD DRIVE SUITE A | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 70806 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2259233733 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2015 | ||||||||
| LastUpdateDate: | 11/12/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 251S00000 | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
ID Information
| ID | Type | State | Issuer | Description | 600964601 | 05 | LA | MEDICAID |