Provider Demographics
NPI:1629151311
Name:EDUCATIONAL AND DEVELOPMENTAL INTERVENTION SERVICES
Entity Type:Organization
Organization Name:EDUCATIONAL AND DEVELOPMENTAL INTERVENTION SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OCCUPATIONAL THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:MADELYN
Authorized Official - Middle Name:PRISCILLA
Authorized Official - Last Name:WASHINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:409-468-7811
Mailing Address - Street 1:235TH BSB BOX 215 CMR 463
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09177-9177
Mailing Address - Country:US
Mailing Address - Phone:001-468-7644
Mailing Address - Fax:001-468-7853
Practice Address - Street 1:235TH BSB BOX 215 CMR 463 09177
Practice Address - Street 2:
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09177-8614
Practice Address - Country:US
Practice Address - Phone:01149981-183-7644
Practice Address - Fax:00149981-183-8753
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2010-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201006825261QD1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities