Provider Demographics
NPI:1265000608
Name:EDWARDS, AUDREA
Entity Type:Individual
Prefix:
First Name:AUDREA
Middle Name:
Last Name:EDWARDS
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 1:1217 W MCALESTER AVE
Mailing Address - Street 2:
Mailing Address - City:SULPHUR
Mailing Address - State:OK
Mailing Address - Zip Code:73086-5445
Mailing Address - Country:US
Mailing Address - Phone:580-618-3401
Mailing Address - Fax:
Practice Address - Street 1:1814 W OWEN K GARRIOTT RD
Practice Address - Street 2:
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73703-5525
Practice Address - Country:US
Practice Address - Phone:580-823-8017
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-13
Last Update Date:2021-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKBACB646004106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician