Basic Information
| Provider Information | |||||||||
| NPI: | 1275954687 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EDWARDS | ||||||||
| FirstName: | MICHELLE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8507 WAYLAND ST | ||||||||
| Address2: | |||||||||
| City: | NORFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 235033939 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7575476819 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4301 N FEDERAL HWY STE 2 | ||||||||
| Address2: | |||||||||
| City: | POMPANO BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330646519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8888809270 | ||||||||
| FaxNumber: | 9543420273 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/02/2014 | ||||||||
| LastUpdateDate: | 01/02/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.