Healthcare Provider Details

I. General information

NPI: 1497399307
Provider Name (Legal Business Name): TISEANNA EDWARDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/04/2019
Last Update Date: 11/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1070 RANGE RD
PORT HURON MI
48060-4606
US

IV. Provider business mailing address

1070 RANGE RD
PORT HURON MI
48060-4606
US

V. Phone/Fax

Practice location:
  • Phone: 810-937-2345
  • Fax:
Mailing address:
  • Phone: 810-937-2345
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: