Provider Demographics
NPI:1588711790
Name:EDWARDS, JANIS L (LCSW)
Entity type:Individual
Prefix:
First Name:JANIS
Middle Name:L
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:408 ELMORE ST
Mailing Address - Street 2:
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-3437
Mailing Address - Country:US
Mailing Address - Phone:484-678-3786
Mailing Address - Fax:
Practice Address - Street 1:408 ELMORE ST
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-3437
Practice Address - Country:US
Practice Address - Phone:484-678-3786
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEQ1-0000434101YM0800X
IL149.014777101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1000015367Medicaid
DE1000015367Medicaid
DE248255000Medicare UPIN
DE2318711000Medicare UPIN
DE7741009Medicare UPIN
DE490985Medicare ID - Type Unspecified
DE189100Medicare UPIN