Provider Demographics
NPI:1124153838
Name:EDWARDS, CHARLES RANDALL (PHD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:RANDALL
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:202 FAIRVIEW RD
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27360-3822
Mailing Address - Country:US
Mailing Address - Phone:336-472-7509
Mailing Address - Fax:
Practice Address - Street 1:1303 GREENSBORO STREET EXT
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:NC
Practice Address - Zip Code:27295-1924
Practice Address - Country:US
Practice Address - Phone:336-249-0237
Practice Address - Fax:336-243-7685
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-22
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0879103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6000633Medicaid