Provider Demographics
NPI:1396280574
Name:EDWARDS, LISETTE CAROLA (LPC)
Entity type:Individual
Prefix:
First Name:LISETTE
Middle Name:CAROLA
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12300 WASHINGTON HWY
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:VA
Mailing Address - Zip Code:23005-7646
Mailing Address - Country:US
Mailing Address - Phone:804-365-4222
Mailing Address - Fax:
Practice Address - Street 1:12300 WASHINGTON HWY
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:VA
Practice Address - Zip Code:23005-7646
Practice Address - Country:US
Practice Address - Phone:804-365-4222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-27
Last Update Date:2020-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPCCI 3567101YP2500X
VA07010008955101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1104858653Medicaid