Provider Demographics
NPI:1144525825
Name:EDWARDS, DIETTRA YVONNE (CBHCM)
Entity type:Individual
Prefix:
First Name:DIETTRA
Middle Name:YVONNE
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:CBHCM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 NW 63RD ST
Mailing Address - Street 2:SUITE 140
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73116-7907
Mailing Address - Country:US
Mailing Address - Phone:405-639-2080
Mailing Address - Fax:405-639-3077
Practice Address - Street 1:301 NW 63RD ST
Practice Address - Street 2:SUITE 140
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73116-7907
Practice Address - Country:US
Practice Address - Phone:405-639-2080
Practice Address - Fax:405-639-3077
Is Sole Proprietor?:No
Enumeration Date:2011-01-11
Last Update Date:2011-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK23156104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker