Provider Demographics
NPI:1780300871
Name:EDWARDS, MICHAEL SCOTT
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:SCOTT
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1530 CORNERSTONE BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32117-7129
Mailing Address - Country:US
Mailing Address - Phone:386-274-0341
Mailing Address - Fax:
Practice Address - Street 1:MICHAEL EDWARDS
Practice Address - Street 2:1452 ATLANTA DR
Practice Address - City:HOLLY HILL
Practice Address - State:FL
Practice Address - Zip Code:32117
Practice Address - Country:US
Practice Address - Phone:386-274-8089
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-19
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL8004653202Medicaid