Healthcare Provider Details

I. General information

NPI: 1396942611
Provider Name (Legal Business Name): LAURIE EDWARDS PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2007
Last Update Date: 12/11/2023
Certification Date: 12/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

430 ALTA VISTA ST STE 5
SANTA FE NM
87505-4140
US

IV. Provider business mailing address

903 W ALAMEDA ST
SANTA FE NM
87501-1681
US

V. Phone/Fax

Practice location:
  • Phone: 808-772-0423
  • Fax: 866-821-5133
Mailing address:
  • Phone: 808-772-0423
  • Fax: 866-821-5133

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY1108
License Number StateHI
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY1540
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: