Provider Demographics
NPI:1225497480
Name:EDGE, MARY ELLEN
Entity Type:Individual
Prefix:
First Name:MARY ELLEN
Middle Name:
Last Name:EDGE
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 1:206 VILLAGE CENTER BLVD
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:DE
Mailing Address - Zip Code:19968-1378
Mailing Address - Country:US
Mailing Address - Phone:610-574-0833
Mailing Address - Fax:
Practice Address - Street 1:206 VILLAGE CENTER BLVD
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:DE
Practice Address - Zip Code:19968-1378
Practice Address - Country:US
Practice Address - Phone:610-574-0833
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-16
Last Update Date:2016-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEQ1-00009311041C0700X
DEL1-0036355163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No163W00000XNursing Service ProvidersRegistered Nurse