Healthcare Provider Details

I. General information

NPI: 1790020261
Provider Name (Legal Business Name): JOSEPHINE MONIQUE EDGE LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/10/2012
Last Update Date: 02/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4510 FRANKFORD AVE 2ND FLOOR
PHILADELPHIA PA
19124-3602
US

IV. Provider business mailing address

432 N 6TH ST
PHILADELPHIA PA
19123-4004
US

V. Phone/Fax

Practice location:
  • Phone: 215-831-9882
  • Fax: 215-831-9887
Mailing address:
  • Phone: 215-925-2400
  • Fax: 215-925-9162

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMF000579
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: