Provider Demographics
NPI:1922354224
Name:EDWARDS, MICHELLE (LLP)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1142 11TH ST
Mailing Address - Street 2:
Mailing Address - City:WYANDOTTE
Mailing Address - State:MI
Mailing Address - Zip Code:48192-3130
Mailing Address - Country:US
Mailing Address - Phone:734-286-1227
Mailing Address - Fax:
Practice Address - Street 1:13101 ALLEN RD
Practice Address - Street 2:
Practice Address - City:SOUTHGATE
Practice Address - State:MI
Practice Address - Zip Code:48195-2216
Practice Address - Country:US
Practice Address - Phone:734-785-7700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-24
Last Update Date:2019-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301014497103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical