Provider Demographics
NPI:1346314762
Name:EDWARDS, WILLIAM BRYAN (LADC)
Entity type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:BRYAN
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:LADC
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 335
Mailing Address - Street 2:104 1ST ST. NW
Mailing Address - City:DODGE CENTER
Mailing Address - State:MN
Mailing Address - Zip Code:55927-0335
Mailing Address - Country:US
Mailing Address - Phone:507-374-9047
Mailing Address - Fax:507-374-2977
Practice Address - Street 1:104 1ST ST NW
Practice Address - Street 2:
Practice Address - City:DODGE CENTER
Practice Address - State:MN
Practice Address - Zip Code:55927-9195
Practice Address - Country:US
Practice Address - Phone:507-374-9047
Practice Address - Fax:507-374-2977
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN300682101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)