Provider Demographics
NPI:1821841628
Name:EDWARDS, MAXREN
Entity Type:Individual
Prefix:
First Name:MAXREN
Middle Name:
Last Name:EDWARDS
Suffix:
Gender:U
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4421 WINDSOR DR APT 57
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72904-5763
Mailing Address - Country:US
Mailing Address - Phone:479-392-8855
Mailing Address - Fax:
Practice Address - Street 1:4421 WINDSOR DR APT 57
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72904-5763
Practice Address - Country:US
Practice Address - Phone:479-392-8855
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-10
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician