Provider Demographics
NPI:1235722240
Name:EDWARDS, CHRISTIAN
Entity Type:Individual
Prefix:
First Name:CHRISTIAN
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 1:225 VANDALIA AVE APT 18B
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11239-1416
Mailing Address - Country:US
Mailing Address - Phone:347-256-5051
Mailing Address - Fax:
Practice Address - Street 1:17320 W 12 MILE RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-2100
Practice Address - Country:US
Practice Address - Phone:248-727-3456
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-19
Last Update Date:2022-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6851114263104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker