Provider Demographics
NPI:1699170365
Name:EDWARDS, LARRY (LMSW)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19005 122ND AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:SPRINGFIELD GARDENS
Mailing Address - State:NY
Mailing Address - Zip Code:11413-1010
Mailing Address - Country:US
Mailing Address - Phone:646-824-5737
Mailing Address - Fax:
Practice Address - Street 1:19005 122ND AVE
Practice Address - Street 2:SUITE A
Practice Address - City:SPRINGFIELD GARDENS
Practice Address - State:NY
Practice Address - Zip Code:11413-1010
Practice Address - Country:US
Practice Address - Phone:646-824-5737
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-23
Last Update Date:2014-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY092982101Y00000X, 104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical