Provider Demographics
NPI:1770139644
Name:EDWARDS, DESTI SHEPARD (PHD)
Entity type:Individual
Prefix:
First Name:DESTI
Middle Name:SHEPARD
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 CENTRAL PARK DR APT 303
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73105-1716
Mailing Address - Country:US
Mailing Address - Phone:225-278-1857
Mailing Address - Fax:
Practice Address - Street 1:1200 CHILDRENS AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73104-4637
Practice Address - Country:US
Practice Address - Phone:405-271-4407
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-15
Last Update Date:2019-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist