Provider Demographics
NPI:1639042534
Name:EDWARDS, MARCELLUAS LAVONTE
Entity type:Individual
Prefix:
First Name:MARCELLUAS
Middle Name:LAVONTE
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20220 GLEN RUSS LN
Mailing Address - Street 2:
Mailing Address - City:EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44117-2417
Mailing Address - Country:US
Mailing Address - Phone:330-368-2400
Mailing Address - Fax:
Practice Address - Street 1:20220 GLEN RUSS LN
Practice Address - Street 2:
Practice Address - City:EUCLID
Practice Address - State:OH
Practice Address - Zip Code:44117-2417
Practice Address - Country:US
Practice Address - Phone:330-368-2400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-26
Last Update Date:2025-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHTS942951171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty