Provider Demographics
NPI:1790154417
Name:EDGEWATER SYSTERMS FOR BALANCED LIVING
Entity Type:Organization
Organization Name:EDGEWATER SYSTERMS FOR BALANCED LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST II
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:BUCKNER
Authorized Official - Suffix:
Authorized Official - Credentials:MA,NCC
Authorized Official - Phone:219-885-4264
Mailing Address - Street 1:1106 WEST 6 TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:GARY
Mailing Address - State:IN
Mailing Address - Zip Code:46402
Mailing Address - Country:US
Mailing Address - Phone:219-885-4264
Mailing Address - Fax:219-885-1332
Practice Address - Street 1:1106 WEST 6 TH AVENUE
Practice Address - Street 2:
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46402
Practice Address - Country:US
Practice Address - Phone:219-885-4264
Practice Address - Fax:219-885-1332
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-23
Last Update Date:2015-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health