Provider Demographics
NPI:1518297332
Name:EDWARDS, RAVONDA LATRICE
Entity type:Individual
Prefix:
First Name:RAVONDA
Middle Name:LATRICE
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 1:500 NW 171ST ST
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73012-6753
Mailing Address - Country:US
Mailing Address - Phone:405-863-0851
Mailing Address - Fax:
Practice Address - Street 1:2220 N CLASSEN BLVD
Practice Address - Street 2:SUITE E
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73106-5809
Practice Address - Country:US
Practice Address - Phone:405-528-0087
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-29
Last Update Date:2009-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKUNDERSUPERVISION101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health