=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033538194
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SARAH R. EDWARDS LP, PH.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/15/2014
-----------------------------------------------------
Last Update Date | 12/31/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3309 FIECHTNER DR S STE H
-----------------------------------------------------
City | FARGO
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58103-2375
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 218-303-6164
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5062 120TH AVE N
-----------------------------------------------------
City | FELTON
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56536-9326
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-762-6292
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 496
-----------------------------------------------------
License Number State | ND
-----------------------------------------------------