Healthcare Provider Details

I. General information

NPI: 1609996339
Provider Name (Legal Business Name): DELORIES EDWARDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 12/17/2024
Certification Date: 12/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 HEALTH CENTER DR
MATTOON IL
61938-9253
US

IV. Provider business mailing address

721 E COURT ST
PARIS IL
61944-2460
US

V. Phone/Fax

Practice location:
  • Phone: 217-258-2525
  • Fax:
Mailing address:
  • Phone: 217-466-4398
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070.015231
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: