Provider Demographics
NPI:1447467428
Name:EDGAR, EDWARD (LADC)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:
Last Name:EDGAR
Suffix:
Gender:M
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 WOLCOTT ST
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06705-1240
Mailing Address - Country:US
Mailing Address - Phone:203-596-7870
Mailing Address - Fax:
Practice Address - Street 1:525 WOLCOTT ST
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06705-1240
Practice Address - Country:US
Practice Address - Phone:203-596-7870
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2012-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000374101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT300000374CT02OtherANTHEM BLUE CROSS
CT300000374CT01OtherANTHEM BLUE CROSS