Provider Demographics
NPI:1548553233
Name:EDWARDS, CAROLYN R
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:R
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1255 E HIGHLAND AVE STE 105B
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92404-4652
Mailing Address - Country:US
Mailing Address - Phone:909-838-0650
Mailing Address - Fax:951-683-4239
Practice Address - Street 1:1255 E HIGHLAND AVE STE 105B
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-4652
Practice Address - Country:US
Practice Address - Phone:909-838-0650
Practice Address - Fax:951-683-4239
Is Sole Proprietor?:No
Enumeration Date:2011-05-27
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X
CA112521101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)