=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407435571
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | IEASHA DENISE EDWARDS MA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/06/2021
-----------------------------------------------------
Last Update Date | 04/06/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16379 E PRESERVE LOOP UNIT 1959
-----------------------------------------------------
City | CHINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91708-8898
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 424-375-9983
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 6350
-----------------------------------------------------
City | NORCO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92860-8045
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 424-375-9983
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 119645
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------