=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245745918
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EDCHA BEHAVIORAL HEALTH, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/04/2017
-----------------------------------------------------
Last Update Date | 12/04/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2670 CRAIN HWY STE 401
-----------------------------------------------------
City | WALDORF
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20601-2818
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-419-2412
-----------------------------------------------------
Fax | 240-419-2495
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2670 CRAIN HWY STE 401
-----------------------------------------------------
City | WALDORF
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20601-2818
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-419-2412
-----------------------------------------------------
Fax | 240-419-2495
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CRNP/ OWNER
-----------------------------------------------------
Name | EDNER CHARLES
-----------------------------------------------------
Credential | CRNP
-----------------------------------------------------
Telephone | 240-419-2412
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | R229551
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------