Provider Demographics
NPI:1962890780
Name:EDWARDS, LARRY (LLMSW)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2081 W GRAND BLVD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48208-1105
Mailing Address - Country:US
Mailing Address - Phone:313-895-0500
Mailing Address - Fax:313-895-4425
Practice Address - Street 1:2081 W GRAND BLVD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48208-1105
Practice Address - Country:US
Practice Address - Phone:313-895-0500
Practice Address - Fax:313-895-4425
Is Sole Proprietor?:No
Enumeration Date:2014-12-31
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MISA 820123101YA0400X
MI68511080481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)