Provider Demographics
NPI:1033265376
Name:EDMONDSON, WILLARD ELBERT JR (LICSW)
Entity Type:Individual
Prefix:MR
First Name:WILLARD
Middle Name:ELBERT
Last Name:EDMONDSON
Suffix:JR
Gender:M
Credentials:LICSW
Other - Prefix:MR
Other - First Name:EDDIE
Other - Middle Name:
Other - Last Name:EDMONDSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LICSW
Mailing Address - Street 1:613 19TH AVE E
Mailing Address - Street 2:SUITE 102
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98112-4075
Mailing Address - Country:US
Mailing Address - Phone:206-322-5733
Mailing Address - Fax:
Practice Address - Street 1:613 19TH AVE E
Practice Address - Street 2:SUITE 102
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98112-4075
Practice Address - Country:US
Practice Address - Phone:206-322-5733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-27
Last Update Date:2011-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW000052121041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical