MEDICARE: LISA N EDWARDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	222Q00000X	Developmental Therapist	2139132	DE

General Provider Information

NPI Number	:	1215814298
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA N EDWARDS

Provider Business Mailing Address
First Line	:	3514 K ST UNIT 1
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19134-1413
Country	:	US
Telephone Number	:	267-516-1425
Fax Number	:	267-516-1425

Provider Business Practice Location Address
First Line	:	3514 K ST UNIT 1
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19134-1413
Country	:	US
Telephone Number	:	267-516-1425
Fax Number	:	267-516-1425

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/20/2025
Last Update Date	:	08/20/2025

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