Provider Demographics
NPI:1932135167
Name:EDWARDS, MARIKO RAE (MPT)
Entity Type:Individual
Prefix:MS
First Name:MARIKO
Middle Name:RAE
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10474 SANTA MONICA BLVD
Mailing Address - Street 2:SUITE 435
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-6929
Mailing Address - Country:US
Mailing Address - Phone:310-275-4137
Mailing Address - Fax:310-274-1815
Practice Address - Street 1:10474 SANTA MONICA BLVD
Practice Address - Street 2:SUITE 421
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-6929
Practice Address - Country:US
Practice Address - Phone:310-275-4137
Practice Address - Fax:310-274-1815
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2012-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 26143225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP39385Medicare UPIN