Provider Demographics
NPI:1316003825
Name:GARRETT, EDWINA B (MA)
Entity type:Individual
Prefix:
First Name:EDWINA
Middle Name:B
Last Name:GARRETT
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6348
Mailing Address - Street 2:
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:NC
Mailing Address - Zip Code:27802-6348
Mailing Address - Country:US
Mailing Address - Phone:252-442-5771
Mailing Address - Fax:252-442-5780
Practice Address - Street 1:107 S.E. MAIN STREET
Practice Address - Street 2:SUITE 410
Practice Address - City:ROCKY MOUNT
Practice Address - State:NC
Practice Address - Zip Code:27801
Practice Address - Country:US
Practice Address - Phone:252-442-5771
Practice Address - Fax:252-442-5780
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1566103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6107398Medicaid
NC144HWOtherBLUECROSS BLUESHIELD
NC196488OtherMEDCOST