Provider Demographics
NPI:1942854708
Name:EDWARDS, MAKAYLI
Entity Type:Individual
Prefix:
First Name:MAKAYLI
Middle Name:
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3214 BROKEN ROCK WAY
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:UT
Mailing Address - Zip Code:84780-7901
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:230 N 1680 E
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-2579
Practice Address - Country:US
Practice Address - Phone:435-313-4571
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-30
Last Update Date:2019-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UTRBT-19-89918103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst