Provider Demographics
NPI:1932095478
Name:EDWARDS, MARIAH LEILANI
Entity type:Individual
Prefix:
First Name:MARIAH
Middle Name:LEILANI
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 1:406 SCENIC VIEW CT
Mailing Address - Street 2:
Mailing Address - City:VILLA RICA
Mailing Address - State:GA
Mailing Address - Zip Code:30180-7059
Mailing Address - Country:US
Mailing Address - Phone:917-854-5601
Mailing Address - Fax:
Practice Address - Street 1:406 SCENIC VIEW CT
Practice Address - Street 2:
Practice Address - City:VILLA RICA
Practice Address - State:GA
Practice Address - Zip Code:30180-7059
Practice Address - Country:US
Practice Address - Phone:917-854-5601
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-12
Last Update Date:2025-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-25-413262106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician