Provider Demographics
NPI:1548510217
Name:NG, EDNA (LCSW,SAP,CRADC,PCGC)
Entity type:Individual
Prefix:
First Name:EDNA
Middle Name:
Last Name:NG
Suffix:
Gender:F
Credentials:LCSW,SAP,CRADC,PCGC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10806 N OVERTONE ST
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-7480
Mailing Address - Country:US
Mailing Address - Phone:309-922-3177
Mailing Address - Fax:
Practice Address - Street 1:4809 N SHERIDAN RD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-5927
Practice Address - Country:US
Practice Address - Phone:309-922-3177
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-11
Last Update Date:2014-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490138671041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical