Healthcare Provider Details

I. General information

NPI: 1639168958
Provider Name (Legal Business Name): EDWIN R AILES LMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/19/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 E 15TH ST
PANAMA CITY FL
32405-5412
US

IV. Provider business mailing address

525 E 15TH ST
PANAMA CITY FL
32405-5412
US

V. Phone/Fax

Practice location:
  • Phone: 850-522-4485
  • Fax: 850-914-6281
Mailing address:
  • Phone: 850-522-4485
  • Fax: 850-914-6281

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMT 140
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: