Provider Demographics
NPI:1972169555
Name:EDWARDS, DIANE
Entity Type:Individual
Prefix:
First Name:DIANE
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 1:3203 GLENMOOR DR
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33409-2822
Mailing Address - Country:US
Mailing Address - Phone:954-515-9722
Mailing Address - Fax:
Practice Address - Street 1:3203 GLENMOOR DR
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33409-2822
Practice Address - Country:US
Practice Address - Phone:954-515-9722
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-19
Last Update Date:2019-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1984131106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1984131OtherBACB