Basic Information
| Provider Information | |||||||||
| NPI: | 1952476152 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EDWARDS | ||||||||
| FirstName: | GEORGE | ||||||||
| MiddleName: | KEVIN | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MA LPA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1321 ARBOR RIDGE WAY | ||||||||
| Address2: | |||||||||
| City: | LELAND | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28451 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104092758 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2250 SHIPYARD BLVD SUITE 3 | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9107919625 | ||||||||
| FaxNumber: | 9107929799 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/22/2006 | ||||||||
| 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 | 2391 | NC | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 136MC | 01 | NC | BCBS | OTHER | 2875996 | 05 | NC | MEDICAID |