MEDICARE: EDGEWOOD MENTAL HEALTH AND WELLNESS LLC

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	171W00000X	Contractor
2	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1922859198
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EDGEWOOD MENTAL HEALTH AND WELLNESS LLC

Provider Business Mailing Address
First Line	:	24815 S ELLSWORTH RD APT 179
Second Line	:
City	:	QUEEN CREEK
State	:	AZ
Zip	:	85142-1929
Country	:	US
Telephone Number	:	503-308-1301
Fax Number	:	503-217-6526

Provider Business Practice Location Address
First Line	:	280 LIBERTY ST SE STE 206
Second Line	:
City	:	SALEM
State	:	OR
Zip	:	97301-3554
Country	:	US
Telephone Number	:	503-308-1301
Fax Number	:	503-217-6526

Authorized Official
Title or Position	:	OWNER
Name	:	EMMA LIME
Credential	:
Telephone Number	:	503-308-1301

Provider Enumeration Date	:	03/27/2024
Last Update Date	:	01/12/2026

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