Provider Demographics
NPI:1700379906
Name:EDELMAN, AUDREY MAY
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:MAY
Last Name:EDELMAN
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 1:54 PILGRIM RD # 271
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215-4127
Mailing Address - Country:US
Mailing Address - Phone:781-801-6336
Mailing Address - Fax:
Practice Address - Street 1:54 PILGRIM RD # 271
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-4127
Practice Address - Country:US
Practice Address - Phone:781-801-6336
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-12
Last Update Date:2018-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician