Provider Demographics
NPI:1881063196
Name:EDGEWATER SYSTEMS
Entity type:Organization
Organization Name:EDGEWATER SYSTEMS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:KENISHA
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:PEDEN
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:219-240-8615
Mailing Address - Street 1:1100 W 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:GARY
Mailing Address - State:IN
Mailing Address - Zip Code:46402-1711
Mailing Address - Country:US
Mailing Address - Phone:219-240-8615
Mailing Address - Fax:219-977-1197
Practice Address - Street 1:4747 W 24TH AVE
Practice Address - Street 2:
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46406-2821
Practice Address - Country:US
Practice Address - Phone:219-240-8615
Practice Address - Fax:219-977-1197
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-16
Last Update Date:2015-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility