Basic Information
Provider Information | |||||||||
NPI: | 1932209921 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | EDENS | ||||||||
FirstName: | CONNIE | ||||||||
MiddleName: | P | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | L.C.S.W. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 102 HERITAGE WAY NE | ||||||||
Address2: | SUITE 302 | ||||||||
City: | LEESBURG | ||||||||
State: | VA | ||||||||
PostalCode: | 201764544 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7037715168 | ||||||||
FaxNumber: | 7037770170 | ||||||||
Practice Location | |||||||||
Address1: | 102 HERITAGE WAY NE | ||||||||
Address2: | SUITE 302 | ||||||||
City: | LEESBURG | ||||||||
State: | VA | ||||||||
PostalCode: | 201764544 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7037715100 | ||||||||
FaxNumber: | 7037770170 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/22/2006 | ||||||||
LastUpdateDate: | 09/10/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 0904004723 | VA | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
ID | Type | State | Issuer | Description | 219058 | 01 | VA | ANTHEM AT ELMHC | OTHER | 293481 | 01 | VA | AMERIGROUP | OTHER | 219059 | 01 | VA | ANTHEM AT LEESBURG | OTHER |