Provider Demographics
NPI:1114360278
Name:EDWARDS, SIRFREEBIRD
Entity Type:Individual
Prefix:
First Name:SIRFREEBIRD
Middle Name:
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:623 E ILLINOIS AVE
Mailing Address - Street 2:
Mailing Address - City:ENID
Mailing Address - State:OK
Mailing Address - Zip Code:73701-7573
Mailing Address - Country:US
Mailing Address - Phone:580-977-8602
Mailing Address - Fax:
Practice Address - Street 1:623 E ILLINOIS AVE
Practice Address - Street 2:
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73701-7573
Practice Address - Country:US
Practice Address - Phone:580-977-8602
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-09
Last Update Date:2013-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK102X00000X
104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No102X00000XBehavioral Health & Social Service ProvidersPoetry Therapist