Healthcare Provider Details

I. General information

NPI: 1982495925
Provider Name (Legal Business Name): EDGE THERAPY AND LIFE COACHING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2025
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3616 N MERIDIAN AVE STE 111
OKLAHOMA CITY OK
73112-2814
US

IV. Provider business mailing address

6101 CHERRY AVE STE 205
FONTANA CA
92336-5362
US

V. Phone/Fax

Practice location:
  • Phone: 909-202-8403
  • Fax: 909-697-2887
Mailing address:
  • Phone: 909-202-8361
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: MONIQUE BAUTISTA
Title or Position: DIRECTOR
Credential: LCSW
Phone: 909-202-8361