Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 101Y00000X | Counselor | ||
N | 101YP1600X | Pastoral Counselor | ||
N | 225700000X | Massage Therapist |
NPI | 1295964088 |
---|---|
Provider Name | Mr. Michael J Edwards SR. |
First Address | Summit, MS 39666-9079 |
Second Address | Mesquite, TX 75150-3309 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 14/07/2009 |
Last Update Date | 20/01/2012 |