Provider Demographics
NPI:1174970719
Name:EDGEWOOD CENTER FOR CHILDREN & FAMILIES
Entity type:Organization
Organization Name:EDGEWOOD CENTER FOR CHILDREN & FAMILIES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHILD CARE COUNSELOR
Authorized Official - Prefix:MS
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:D
Authorized Official - Last Name:RAY
Authorized Official - Suffix:
Authorized Official - Credentials:MBA/PA
Authorized Official - Phone:415-994-7410
Mailing Address - Street 1:170 NORTHRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:DALY CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94015-4618
Mailing Address - Country:US
Mailing Address - Phone:415-994-7410
Mailing Address - Fax:
Practice Address - Street 1:170 NORTHRIDGE DR
Practice Address - Street 2:
Practice Address - City:DALY CITY
Practice Address - State:CA
Practice Address - Zip Code:94015-4618
Practice Address - Country:US
Practice Address - Phone:415-994-7410
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-24
Last Update Date:2016-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children