Provider Demographics
NPI:1467201301
Name:EDGE HEALTH CARE AND MENTAL HEALTH SERVICES
Entity type:Organization
Organization Name:EDGE HEALTH CARE AND MENTAL HEALTH SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PMHNP-BC
Authorized Official - Prefix:
Authorized Official - First Name:EKAN
Authorized Official - Middle Name:
Authorized Official - Last Name:EKONG
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:763-498-4448
Mailing Address - Street 1:157 GRASS LAKE PL APT 309
Mailing Address - Street 2:
Mailing Address - City:SHOREVIEW
Mailing Address - State:MN
Mailing Address - Zip Code:55126-2063
Mailing Address - Country:US
Mailing Address - Phone:763-498-4448
Mailing Address - Fax:
Practice Address - Street 1:157 GRASS LAKE PL APT 309
Practice Address - Street 2:
Practice Address - City:SHOREVIEW
Practice Address - State:MN
Practice Address - Zip Code:55126-2063
Practice Address - Country:US
Practice Address - Phone:763-498-4448
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-14
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3245S0500XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilitySubstance Abuse Treatment, ChildrenGroup - Multi-Specialty
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental IllnessGroup - Multi-Specialty