Provider Demographics
NPI:1255857207
Name:EDLER, CHRISTINA
Entity Type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:
Last Name:EDLER
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 1:733 MEADOW RIDGE LN
Mailing Address - Street 2:
Mailing Address - City:LENA
Mailing Address - State:IL
Mailing Address - Zip Code:61048-8722
Mailing Address - Country:US
Mailing Address - Phone:1815-275-0675
Mailing Address - Fax:
Practice Address - Street 1:310 N WEST ST
Practice Address - Street 2:
Practice Address - City:ELIZABETH
Practice Address - State:IL
Practice Address - Zip Code:61028-8017
Practice Address - Country:US
Practice Address - Phone:815-599-1947
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-21
Last Update Date:2017-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool