MEDICARE: LAKEN A EDWARDS BCBA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst	1-24-74078	TN

General Provider Information

NPI Number	:	1659118651
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAKEN A EDWARDS BCBA

Provider Business Mailing Address
First Line	:	7010 DASHWOOD DR
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38119-8504
Country	:	US
Telephone Number	:	601-218-7454
Fax Number	:

Provider Business Practice Location Address
First Line	:	4988 FAIRFIELD CIR S
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38117-4210
Country	:	US
Telephone Number	:	901-827-1115
Fax Number	:	901-370-3289

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/09/2024
Last Update Date	:	07/09/2024

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