Basic Information
| Provider Information | |||||||||
| NPI: | 1699984138 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EDWARDS | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | THEOLA | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4575 NW 91 AVE | ||||||||
| Address2: | |||||||||
| City: | SUNRISE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7543331196 | ||||||||
| FaxNumber: | 3057574465 | ||||||||
| Practice Location | |||||||||
| Address1: | 1400 NW 14 CT. | ||||||||
| Address2: | MASTER MIND CARE, INC. ATTN: ELIZABETH EDWARDS | ||||||||
| City: | FT. LAUDERDALE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7543331196 | ||||||||
| FaxNumber: | 9547856120 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2007 | ||||||||
| LastUpdateDate: | 07/20/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | N | Behavioral Health & Social Service Providers | Social Worker | 104100000X | SW16637 | FL | N | Behavioral Health & Social Service Providers | Social Worker | 1041S0200X | SW16637 | FL | N | Behavioral Health & Social Service Providers | Social Worker | School | 1041C0700X | SW16637 | FL | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | MH684 | 01 | FL | MEDICARE PROVIDER | OTHER |