Healthcare Provider Details

I. General information

NPI: 1821654252
Provider Name (Legal Business Name): SHANICE ROSE EDWARDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2019
Last Update Date: 08/27/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 W HOSPITALITY LN STE 112
SAN BERNARDINO CA
92408-3211
US

IV. Provider business mailing address

325 W HOSPITALITY LN STE 112
SAN BERNARDINO CA
92408-3211
US

V. Phone/Fax

Practice location:
  • Phone: 909-763-5803
  • Fax:
Mailing address:
  • Phone: 909-763-5803
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number141445
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number141445
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: