Provider Demographics
NPI:1396942611
Name:EDWARDS, LAURIE (PHD)
Entity type:Individual
Prefix:DR
First Name:LAURIE
Middle Name:
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:903 W ALAMEDA ST
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87501-1681
Mailing Address - Country:US
Mailing Address - Phone:808-772-0423
Mailing Address - Fax:866-821-5133
Practice Address - Street 1:430 ALTA VISTA ST STE 5
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-4140
Practice Address - Country:US
Practice Address - Phone:808-772-0423
Practice Address - Fax:866-821-5133
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-29
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPSY1108103TC0700X, 103TH0004X, 103TP2701X, 103TB0200X
NMPSY1540103T00000X
CAPSY17482103TH0004X, 103TP2701X, 103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral