Healthcare Provider Details

I. General information

NPI: 1518447184
Provider Name (Legal Business Name): ERICAH ALEECE EDWARDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2018
Last Update Date: 05/04/2026
Certification Date: 05/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 W KORTSEN RD
CASA GRANDE AZ
85122-5910
US

IV. Provider business mailing address

220 W KORTSEN RD
CASA GRANDE AZ
85122-5910
US

V. Phone/Fax

Practice location:
  • Phone: 520-876-3657
  • Fax:
Mailing address:
  • Phone: 520-876-3657
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number10230819
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: