Provider Demographics
NPI:1821051327
Name:EDWARDS, SHELLY L (MA LP)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:L
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:MA LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14115 JAMES RD STE 305
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:MN
Mailing Address - Zip Code:55374-9417
Mailing Address - Country:US
Mailing Address - Phone:763-575-8086
Mailing Address - Fax:320-774-0415
Practice Address - Street 1:14115 JAMES RD STE 305
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:MN
Practice Address - Zip Code:55374-9417
Practice Address - Country:US
Practice Address - Phone:763-575-8086
Practice Address - Fax:320-774-0415
Is Sole Proprietor?:No
Enumeration Date:2006-04-07
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3435103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
6252137OtherUBH
1023461OtherPREFERRED ONE
120585OtherUCARE
MN63325900Medicaid
MN11Q62EDOtherBCBS
HP23171OtherHEALTH PARTNERS