1699959718 NPI number — MS. MARIE CHRISTINE EDSTROM LMT, NCTMB

Table of content: MS. MARIE CHRISTINE EDSTROM LMT, NCTMB (NPI 1699959718)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699959718 NPI number — MS. MARIE CHRISTINE EDSTROM LMT, NCTMB

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EDSTROM
Provider First Name:
MARIE
Provider Middle Name:
CHRISTINE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LMT, NCTMB
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
COURTNEY
Provider Other First Name:
MARIE
Provider Other Middle Name:
CHRISTINE
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1699959718
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/29/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3521 EUCLID AVE
Provider Second Line Business Mailing Address:
APT 2
Provider Business Mailing Address City Name:
BERWYN
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60402-4731
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-999-6016
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3521 EUCLID AVE
Provider Second Line Business Practice Location Address:
APT 2
Provider Business Practice Location Address City Name:
BERWYN
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60402-4731
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-999-6016
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/26/2007

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: 225700000X , with the licence number:  227.008701 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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