Basic Information
| Provider Information | |||||||||
| NPI: | 1265744247 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EDGE | ||||||||
| FirstName: | REBEKA | ||||||||
| MiddleName: | PENA | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | BCBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16636 BAIRD CIR | ||||||||
| Address2: | |||||||||
| City: | EAGLE RIVER | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995776711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2536866958 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6200 LEE VISTA BLVD STE 200 | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328225149 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7544443707 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2010 | ||||||||
| LastUpdateDate: | 10/30/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 1-10-7144 | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.