Provider Demographics
NPI:1316279821
Name:EDWARDS, TERRY JR
Entity type:Individual
Prefix:MR
First Name:TERRY
Middle Name:
Last Name:EDWARDS
Suffix:JR
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 1:5111 AUTO CLUB DR
Mailing Address - Street 2:112
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-2749
Mailing Address - Country:US
Mailing Address - Phone:313-317-2000
Mailing Address - Fax:
Practice Address - Street 1:5111 AUTO CLUB DR
Practice Address - Street 2:112
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-2749
Practice Address - Country:US
Practice Address - Phone:313-317-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-08
Last Update Date:2019-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX645001041C0700X
MI68010915721041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical