Provider Demographics
NPI:1437661444
Name:EDGE, LAURA E (REGISTERED INTERN SW)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:E
Last Name:EDGE
Suffix:
Gender:F
Credentials:REGISTERED INTERN SW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2608 W CARANDIS RD
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33406-5111
Mailing Address - Country:US
Mailing Address - Phone:561-628-6051
Mailing Address - Fax:
Practice Address - Street 1:2640 FOREST HILL BLVD
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33406-5931
Practice Address - Country:US
Practice Address - Phone:561-616-8411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-31
Last Update Date:2017-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty