Basic Information
| Provider Information | |||||||||
| NPI: | 1780103200 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EDWARDS | ||||||||
| FirstName: | MONIQUE | ||||||||
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| Credential: | LLPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20217 AVALON ST | ||||||||
| Address2: | |||||||||
| City: | SAINT CLAIR SHORES | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480803721 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5865308388 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 22811 GREATER MACK AVE STE L2 | ||||||||
| Address2: | |||||||||
| City: | SAINT CLAIR SHORES | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480802057 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5863352006 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2017 | ||||||||
| LastUpdateDate: | 09/15/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 6401016286 | MI | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.