Healthcare Provider Details

I. General information

NPI: 1629151311
Provider Name (Legal Business Name): EDUCATIONAL AND DEVELOPMENTAL INTERVENTION SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 08/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

235TH BSB BOX 215 CMR 463 09177
APO AE
09177-8614
US

IV. Provider business mailing address

235TH BSB BOX 215 CMR 463
APO AE
09177-9177
US

V. Phone/Fax

Practice location:
  • Phone: 011499811837644
  • Fax: 001499811838753
Mailing address:
  • Phone: 1-468-7644
  • Fax: 1-468-7853

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number5201006825
License Number StateMI

VIII. Authorized Official

Name: MS. MADELYN PRISCILLA WASHINGTON
Title or Position: OCCUPATIONAL THERAPIST
Credential:
Phone: 409-468-7811