Provider Demographics
NPI:1538441274
Name:EDWARDS, CONSUELA BERTINA (LPC)
Entity type:Individual
Prefix:
First Name:CONSUELA
Middle Name:BERTINA
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:170 NORTHRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31220-6643
Mailing Address - Country:US
Mailing Address - Phone:478-737-7770
Mailing Address - Fax:
Practice Address - Street 1:6601 ZEBULON RD
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31220-7606
Practice Address - Country:US
Practice Address - Phone:478-477-3383
Practice Address - Fax:478-475-9492
Is Sole Proprietor?:No
Enumeration Date:2011-09-19
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC001766101YP2500X
GALPC006975101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional