Provider Demographics
NPI:1578044475
Name:EDWARDS, DESTINY ANAIS (DESTINY)
Entity Type:Individual
Prefix:
First Name:DESTINY
Middle Name:ANAIS
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:DESTINY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1026 CROMWELL BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21286-3318
Mailing Address - Country:US
Mailing Address - Phone:410-538-1515
Mailing Address - Fax:
Practice Address - Street 1:1026 CROMWELL BRIDGE RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21286-3318
Practice Address - Country:US
Practice Address - Phone:410-538-1515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-28
Last Update Date:2018-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDE-363-139-067-972OtherN/A