Provider Demographics
NPI:1558902593
Name:EDWARDS, MARIBEL A
Entity Type:Individual
Prefix:
First Name:MARIBEL
Middle Name:A
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 1:4403 HONDO DR
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76549-2921
Mailing Address - Country:US
Mailing Address - Phone:661-429-7266
Mailing Address - Fax:
Practice Address - Street 1:3106 S W S YOUNG DR STE B204
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76542-2000
Practice Address - Country:US
Practice Address - Phone:254-312-2188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-01
Last Update Date:2019-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
016156369-01OtherTRICARE