Basic Information
| Provider Information | |||||||||
| NPI: | 1407141476 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EDWARDS | ||||||||
| FirstName: | EVONNE | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LLP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SMITH | ||||||||
| OtherFirstName: | EVONNE | ||||||||
| OtherMiddleName: | M | ||||||||
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| OtherCredential: | LLP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 300 68TH ST SE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495486927 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6164555000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4211 PARKWAY PL SW | ||||||||
| Address2: | |||||||||
| City: | GRANDVILLE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494182695 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6162223700 | ||||||||
| FaxNumber: | 6162223707 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2011 | ||||||||
| LastUpdateDate: | 10/02/2012 | ||||||||
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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 | 103T00000X | 6301014805 | MI | N | Behavioral Health & Social Service Providers | Psychologist | 103T00000X | 6301015324 | MI | Y | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.