Provider Demographics
NPI:1962085456
Name:EDWARDS, JULISA (MSW, CBHCM)
Entity type:Individual
Prefix:
First Name:JULISA
Middle Name:
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:MSW, CBHCM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4433 PINE VILLA CIR
Mailing Address - Street 2:
Mailing Address - City:PACE
Mailing Address - State:FL
Mailing Address - Zip Code:32571-2072
Mailing Address - Country:US
Mailing Address - Phone:251-607-8124
Mailing Address - Fax:
Practice Address - Street 1:4433 PINE VILLA CIR
Practice Address - Street 2:
Practice Address - City:PACE
Practice Address - State:FL
Practice Address - Zip Code:32571-2072
Practice Address - Country:US
Practice Address - Phone:251-607-8124
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-03
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251B00000X
FLCBHCM103581171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No251B00000XAgenciesCase Management