Basic Information
| Provider Information | |||||||||
| NPI: | 1790154417 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EDGEWATER SYSTERMS FOR BALANCED LIVING | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1106 WEST 6 TH AVENUE | ||||||||
| Address2: | |||||||||
| City: | GARY | ||||||||
| State: | IN | ||||||||
| PostalCode: | 46402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2198854264 | ||||||||
| FaxNumber: | 2198851332 | ||||||||
| Practice Location | |||||||||
| Address1: | 1106 WEST 6 TH AVENUE | ||||||||
| Address2: | |||||||||
| City: | GARY | ||||||||
| State: | IN | ||||||||
| PostalCode: | 46402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2198854264 | ||||||||
| FaxNumber: | 2198851332 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2015 | ||||||||
| LastUpdateDate: | 09/23/2015 | ||||||||
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| AuthorizedOfficialLastName: | BUCKNER | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | MICHAEL | ||||||||
| AuthorizedOfficialTitleorPosition: | THERAPIST II | ||||||||
| AuthorizedOfficialTelephone: | 2198854264 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | MA,NCC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
No ID Information.