Provider Demographics
NPI:1962598292
Name:MAKI, EDWIN JADE (LADC BA)
Entity type:Individual
Prefix:MR
First Name:EDWIN
Middle Name:JADE
Last Name:MAKI
Suffix:
Gender:M
Credentials:LADC BA
Other - Prefix:
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Mailing Address - Street 1:5603 HALIFAX AVE NORTH
Mailing Address - Street 2:
Mailing Address - City:BROOKLY LEMEN
Mailing Address - State:MN
Mailing Address - Zip Code:55429
Mailing Address - Country:US
Mailing Address - Phone:763-536-8787
Mailing Address - Fax:
Practice Address - Street 1:7590 LYRIC LANE NE
Practice Address - Street 2:UNITY HOSPITAL
Practice Address - City:FRIDLEY
Practice Address - State:MN
Practice Address - Zip Code:55432
Practice Address - Country:US
Practice Address - Phone:763-236-9300
Practice Address - Fax:763-236-4370
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN301815101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)