=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922360973
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CARLA MARIE EDWARDS PH.D., L.AC., DIPL O
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/14/2012
-----------------------------------------------------
Last Update Date | 12/05/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1601 SHERMAN AVE SUITE 200
-----------------------------------------------------
City | EVANSTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60201
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-525-1309
-----------------------------------------------------
Fax | 847-859-6100
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2100 GREENWOOD ST UNIT 105
-----------------------------------------------------
City | EVANSTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60201-3979
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-525-1309
-----------------------------------------------------
Fax | 847-859-6100
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | 198.000601
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------