=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710425053
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE HONEST EDGE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/07/2017
-----------------------------------------------------
Last Update Date | 02/07/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1350 N WELLS ST F302
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60610-1936
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-336-7090
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3517 E ROCKLEDGE RD
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85044-7025
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-336-7090
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | SHAWNA BURKHART
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 630-336-7090
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 180007525
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------