Provider Demographics
NPI:1326567223
Name:EDWARDS, LANITA MARIE
Entity type:Individual
Prefix:
First Name:LANITA
Middle Name:MARIE
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 TECHNOLOGY CT STE 300
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-2156
Mailing Address - Country:US
Mailing Address - Phone:951-686-8500
Mailing Address - Fax:
Practice Address - Street 1:157 W 5TH ST STE 1
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92415-2156
Practice Address - Country:US
Practice Address - Phone:909-387-8304
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-12
Last Update Date:2024-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA147635106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist