=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427359314
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAURIE EDWARDS PHD PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/08/2010
-----------------------------------------------------
Last Update Date | 01/17/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 430 ALTA VISTA ST STE 5
-----------------------------------------------------
City | SANTA FE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87505-4140
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-772-0423
-----------------------------------------------------
Fax | 866-821-5133
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 903 W ALAMEDA ST
-----------------------------------------------------
City | SANTA FE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87501-1681
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-772-0423
-----------------------------------------------------
Fax | 866-821-5133
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. LAURIE EDWARDS
-----------------------------------------------------
Credential | PHD
-----------------------------------------------------
Telephone | 808-772-0423
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PSY 1108
-----------------------------------------------------
License Number State | HI
-----------------------------------------------------