Provider Demographics
NPI:1144426982
Name:EDWARD, MARIA ESTELA
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:ESTELA
Last Name:EDWARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1760 KELSO AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33460-6036
Mailing Address - Country:US
Mailing Address - Phone:561-577-1620
Mailing Address - Fax:561-650-8058
Practice Address - Street 1:3501 GEORGIA AVE
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33405-1832
Practice Address - Country:US
Practice Address - Phone:561-577-1620
Practice Address - Fax:561-650-8058
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-26
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251E00000X
FL222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL812140100Medicaid
FL693621196Medicaid