MEDICARE: STEPHANIE LAURETTE EDWARDS MA

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	101YM0800X	Mental Health Counselor
2	172V00000X	Community Health Worker	13402	MO

General Provider Information

NPI Number	:	1972150373
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHANIE LAURETTE EDWARDS MA

Provider Business Mailing Address
First Line	:	3608 HEREFORD ST
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63109-1771
Country	:	US
Telephone Number	:	314-243-0815
Fax Number	:

Provider Business Practice Location Address
First Line	:	3608 HEREFORD ST
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63109-1771
Country	:	US
Telephone Number	:	314-243-0815
Fax Number	:

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

Provider Enumeration Date	:	08/20/2019
Last Update Date	:	02/19/2021

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