Basic Information
| Provider Information | |||||||||
| NPI: | 1659848042 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EDWARDS | ||||||||
| FirstName: | MARTINE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 38882 MENTOR AVE | ||||||||
| Address2: | |||||||||
| City: | WILLOUGHBY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440947875 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 1440813910 | ||||||||
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| Practice Location | |||||||||
| Address1: | 24200 CHAGRIN BLVD | ||||||||
| Address2: | |||||||||
| City: | BEACHWOOD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441225550 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2168316466 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2018 | ||||||||
| LastUpdateDate: | 09/27/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 1041C0700X | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.