Provider Demographics
NPI:1073077475
Name:EDMUNDS, DEEIDRA S (LICSW)
Entity Type:Individual
Prefix:
First Name:DEEIDRA
Middle Name:S
Last Name:EDMUNDS
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:DEEIDRA
Other - Middle Name:S
Other - Last Name:BECKETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:401 CENTER ST FRNT B
Mailing Address - Street 2:
Mailing Address - City:IRONTON
Mailing Address - State:OH
Mailing Address - Zip Code:45638-1519
Mailing Address - Country:US
Mailing Address - Phone:740-479-5135
Mailing Address - Fax:
Practice Address - Street 1:302 STATE ST
Practice Address - Street 2:
Practice Address - City:PROCTORVILLE
Practice Address - State:OH
Practice Address - Zip Code:45669-5004
Practice Address - Country:US
Practice Address - Phone:740-479-5135
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-30
Last Update Date:2022-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVDP009453941041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical