Provider Demographics
NPI:1073146775
Name:EDWARDS, REAGAN LEANNE (RBT)
Entity Type:Individual
Prefix:
First Name:REAGAN
Middle Name:LEANNE
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:306 N KENSINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60526-1870
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4778 OVERTON RD
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35210-3803
Practice Address - Country:US
Practice Address - Phone:205-957-0294
Practice Address - Fax:205-957-0298
Is Sole Proprietor?:No
Enumeration Date:2020-02-20
Last Update Date:2020-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALRBT-20-112380106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALRBT-20-112380OtherBACB CERTIFICATION FOR RBT