Provider Demographics
NPI:1346400041
Name:MARY ELIZABETH EDWARDS DBA WHITE PINE THERAPIES
Entity Type:Organization
Organization Name:MARY ELIZABETH EDWARDS DBA WHITE PINE THERAPIES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-364-6206
Mailing Address - Street 1:5355 AMBROSIA AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43235-5556
Mailing Address - Country:US
Mailing Address - Phone:614-364-6206
Mailing Address - Fax:
Practice Address - Street 1:7037 PLUMB RD
Practice Address - Street 2:
Practice Address - City:GALENA
Practice Address - State:OH
Practice Address - Zip Code:43021-9443
Practice Address - Country:US
Practice Address - Phone:614-364-6206
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-16
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2534298Medicaid