Provider Demographics
NPI:1114268406
Name:EDWARDS-ELLIS, LINDA FAYE (MS)
Entity Type:Individual
Prefix:MRS
First Name:LINDA
Middle Name:FAYE
Last Name:EDWARDS-ELLIS
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2835 WINDSOR LN
Mailing Address - Street 2:
Mailing Address - City:MARIANNA
Mailing Address - State:FL
Mailing Address - Zip Code:32448-3722
Mailing Address - Country:US
Mailing Address - Phone:850-482-5837
Mailing Address - Fax:
Practice Address - Street 1:2711 W 15TH ST
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32401-1366
Practice Address - Country:US
Practice Address - Phone:850-769-6001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-11
Last Update Date:2013-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health