Healthcare Provider Details

I. General information

NPI: 1982852075
Provider Name (Legal Business Name): EDRICA MCDOWELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/03/2008
Last Update Date: 04/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17842 CANAVILLE RD
CREAL SPRINGS IL
62922-2809
US

IV. Provider business mailing address

17842 CANAVILLE RD
CREAL SPRINGS IL
62922-2809
US

V. Phone/Fax

Practice location:
  • Phone: 618-923-4112
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number178.004949
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: