Provider Demographics
NPI:1053836023
Name:EDMONDSON, MADELON
Entity Type:Individual
Prefix:
First Name:MADELON
Middle Name:
Last Name:EDMONDSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1875 OLD ALABAMA RD STE 630
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-2264
Mailing Address - Country:US
Mailing Address - Phone:770-744-4276
Mailing Address - Fax:
Practice Address - Street 1:1875 OLD ALABAMA RD STE 630
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-2264
Practice Address - Country:US
Practice Address - Phone:770-744-4276
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-10
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA000180101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional