Provider Demographics
NPI:1548715543
Name:EDWARDS, ALEXA (LMSW)
Entity type:Individual
Prefix:
First Name:ALEXA
Middle Name:
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 W 300 N
Mailing Address - Street 2:
Mailing Address - City:MALAD CITY
Mailing Address - State:ID
Mailing Address - Zip Code:83252-1137
Mailing Address - Country:US
Mailing Address - Phone:208-530-3595
Mailing Address - Fax:208-530-3595
Practice Address - Street 1:215 E 50 S
Practice Address - Street 2:
Practice Address - City:MALAD CITY
Practice Address - State:ID
Practice Address - Zip Code:83252-2300
Practice Address - Country:US
Practice Address - Phone:208-766-2365
Practice Address - Fax:208-766-2364
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-18
Last Update Date:2016-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID35927101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health