Basic Information
| Provider Information | |||||||||
| NPI: | 1861977423 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EDWARDS | ||||||||
| FirstName: | COURTNEY | ||||||||
| MiddleName: | NICOLE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1003 W CLYDE ST | ||||||||
| Address2: | |||||||||
| City: | ANDOVER | ||||||||
| State: | KS | ||||||||
| PostalCode: | 670027811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3162853698 | ||||||||
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| Practice Location | |||||||||
| Address1: | 635 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672033602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3166607500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2018 | ||||||||
| LastUpdateDate: | 06/10/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 3065 | KS | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.