Provider Demographics
NPI:1174124036
Name:EDWARDS, REGINALD WASHINGTON (LCSW)
Entity type:Individual
Prefix:
First Name:REGINALD
Middle Name:WASHINGTON
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:REGINALD
Other - Middle Name:
Other - Last Name:EDWARDS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:18660 WALNUT AVE
Mailing Address - Street 2:
Mailing Address - City:COUNTRY CLUB HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60478-5549
Mailing Address - Country:US
Mailing Address - Phone:708-600-5752
Mailing Address - Fax:
Practice Address - Street 1:18660 WALNUT AVE
Practice Address - Street 2:
Practice Address - City:COUNTRY CLUB HILLS
Practice Address - State:IL
Practice Address - Zip Code:60478-5549
Practice Address - Country:US
Practice Address - Phone:708-600-5752
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-05
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0225831041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical