Provider Demographics
NPI:1699984138
Name:EDWARDS, ELIZABETH THEOLA (LCSW)
Entity type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:THEOLA
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 1:4575 NW 91 AVE
Mailing Address - Street 2:
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33351
Mailing Address - Country:US
Mailing Address - Phone:754-333-1196
Mailing Address - Fax:305-757-4465
Practice Address - Street 1:1400 NW 14 CT.
Practice Address - Street 2:MASTER MIND CARE, INC. ATTN: ELIZABETH EDWARDS
Practice Address - City:FT. LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33311
Practice Address - Country:US
Practice Address - Phone:754-333-1196
Practice Address - Fax:954-785-6120
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2020-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
FLSW16637104100000X, 1041S0200X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMH684OtherMEDICARE PROVIDER