1437340130 NPI number — TAMMY E. EDGE LPC, EDS

Table of content: TAMMY E. EDGE LPC, EDS (NPI 1437340130)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437340130 NPI number — TAMMY E. EDGE LPC, EDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EDGE
Provider First Name:
TAMMY
Provider Middle Name:
E.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LPC, EDS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1437340130
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/01/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1101 HILLCREST PKWY # 227
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DUBLIN
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31021-3562
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
478-290-5148
Provider Business Mailing Address Fax Number:
478-272-8181

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
306 ACADEMY AVE STE 206
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DUBLIN
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31021-5286
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
478-216-6708
Provider Business Practice Location Address Fax Number:
478-272-8181
Provider Enumeration Date:
08/07/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  004884 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 103TS0200X , with the licence number: 454690 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 003169803A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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