Provider Demographics
NPI:1578099255
Name:EDWARDS, MARTY ROWLAND (LMFT)
Entity Type:Individual
Prefix:
First Name:MARTY
Middle Name:ROWLAND
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:MARTY
Other - Middle Name:ROWLAND
Other - Last Name:EDWARDS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMFT
Mailing Address - Street 1:87003 PROFESSIONAL WAY
Mailing Address - Street 2:
Mailing Address - City:YULEE
Mailing Address - State:FL
Mailing Address - Zip Code:32097-3400
Mailing Address - Country:US
Mailing Address - Phone:904-849-1190
Mailing Address - Fax:
Practice Address - Street 1:87003 PROFESSIONAL WAY
Practice Address - Street 2:
Practice Address - City:YULEE
Practice Address - State:FL
Practice Address - Zip Code:32097-3400
Practice Address - Country:US
Practice Address - Phone:904-849-1190
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-02
Last Update Date:2017-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMT3313106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist