Provider Demographics
NPI:1831965888
Name:CHASE, EDITH
Entity type:Individual
Prefix:
First Name:EDITH
Middle Name:
Last Name:CHASE
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 1:9169 W STATE ST # 1605
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83714-1733
Mailing Address - Country:US
Mailing Address - Phone:310-654-0609
Mailing Address - Fax:
Practice Address - Street 1:3771 NESCONSET HWY STE 214
Practice Address - Street 2:
Practice Address - City:SOUTH SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11720-1154
Practice Address - Country:US
Practice Address - Phone:347-450-1136
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-30
Last Update Date:2023-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY125927106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist