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General NPI Number Information
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NPI Number | 1699225698
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Entity Type | Organization
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Legal Business Name | EDGEWATER SYSTEMS FOR BALANCED LIVING, INC.
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Dates
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Enumeration Date | 10/13/2016
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Last Update Date | 11/22/2024
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Provider Practice Location Address
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Address Line | 5495 BROADWAY
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City | MERRILLVILLE
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State | IN
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Zip | 46410-1647
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Country | US
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Telephone | 219-884-4900
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Fax | 219-980-7585
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Provider Business Mailing Address
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Address Line | 1100 W 6TH AVE
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City | GARY
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State | IN
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Zip | 46402-1711
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Country | US
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Telephone | 219-885-4264
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Fax | 219-882-0962
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Authorized Official
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Title or Position | PRESIDENT/CEO
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Name | DR. DANITA JOHNSON HUGHES
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Credential | PHD.
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Telephone | 219-885-4264
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 01033511A
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License Number State | IN
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