Provider Demographics
NPI:1144714791
Name:EDWARDS-EASLEY, ROSELLA KIM (LCAS-A, LPC-A)
Entity type:Individual
Prefix:
First Name:ROSELLA
Middle Name:KIM
Last Name:EDWARDS-EASLEY
Suffix:
Gender:F
Credentials:LCAS-A, LPC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6652 RIDGE BLUFF DR
Mailing Address - Street 2:
Mailing Address - City:RURAL HALL
Mailing Address - State:NC
Mailing Address - Zip Code:27045-9873
Mailing Address - Country:US
Mailing Address - Phone:336-866-9526
Mailing Address - Fax:
Practice Address - Street 1:4035 UNIVERSITY PKWY STE 101
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27106-3275
Practice Address - Country:US
Practice Address - Phone:336-866-9526
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-18
Last Update Date:2019-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC101YA0400X
NCLCAS-24307101YA0400X
NCA14670101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)