Provider Demographics
NPI:1184757841
Name:SHRADER, EDWIN (MFT)
Entity type:Individual
Prefix:
First Name:EDWIN
Middle Name:
Last Name:SHRADER
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1317 HUNTINGTON DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91030-4511
Mailing Address - Country:US
Mailing Address - Phone:323-344-5538
Mailing Address - Fax:323-344-5550
Practice Address - Street 1:1317 HUNTINGTON DR
Practice Address - Street 2:
Practice Address - City:SOUTH PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91030-4511
Practice Address - Country:US
Practice Address - Phone:323-344-5538
Practice Address - Fax:323-344-5550
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22478106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist