Healthcare Provider Details

I. General information

NPI: 1962085456
Provider Name (Legal Business Name): JULISA EDWARDS MSW, CBHCM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/03/2021
Last Update Date: 05/24/2021
Certification Date: 05/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4433 PINE VILLA CIR
PACE FL
32571-2072
US

IV. Provider business mailing address

4433 PINE VILLA CIR
PACE FL
32571-2072
US

V. Phone/Fax

Practice location:
  • Phone: 251-607-8124
  • Fax:
Mailing address:
  • Phone: 251-607-8124
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License NumberCBHCM103581
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: