Provider Demographics
NPI:1003186016
Name:EDMONDSON, CRAIG KENDALL (BS ED BHRS)
Entity Type:Individual
Prefix:
First Name:CRAIG
Middle Name:KENDALL
Last Name:EDMONDSON
Suffix:
Gender:M
Credentials:BS ED BHRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:84 PECAN ST
Mailing Address - Street 2:
Mailing Address - City:DURANT
Mailing Address - State:OK
Mailing Address - Zip Code:74701-7400
Mailing Address - Country:US
Mailing Address - Phone:903-293-6466
Mailing Address - Fax:
Practice Address - Street 1:801 E MAIN ST
Practice Address - Street 2:
Practice Address - City:TISHOMINGO
Practice Address - State:OK
Practice Address - Zip Code:73460-2351
Practice Address - Country:US
Practice Address - Phone:580-371-3776
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-06
Last Update Date:2012-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health