Provider Demographics
NPI:1811104417
Name:EDWARDS, MARY ELLEN (LCSW)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ELLEN
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 1:1310 S MAGNOLIA AVE
Mailing Address - Street 2:
Mailing Address - City:MONROVIA
Mailing Address - State:CA
Mailing Address - Zip Code:91016-4022
Mailing Address - Country:US
Mailing Address - Phone:818-726-8609
Mailing Address - Fax:
Practice Address - Street 1:410 ARDEN AVE STE 201
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91203-4006
Practice Address - Country:US
Practice Address - Phone:626-390-7304
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2018-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX140331041C0700X
CALCSW223601041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical