Provider Demographics
NPI:1679880413
Name:EDWARDS, PHILIP
Entity type:Individual
Prefix:MR
First Name:PHILIP
Middle Name:
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3916 MESA DRIVE
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75074
Mailing Address - Country:US
Mailing Address - Phone:903-918-9891
Mailing Address - Fax:
Practice Address - Street 1:2222 W SPRING CREEK PKWY
Practice Address - Street 2:SUITE 116
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75023-4183
Practice Address - Country:US
Practice Address - Phone:972-964-3214
Practice Address - Fax:972-964-3044
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-31
Last Update Date:2010-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX18680101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1785685Medicaid