Provider Demographics
NPI:1073893392
Name:EDMON, KATRINA DAHL (LMSW)
Entity Type:Individual
Prefix:
First Name:KATRINA
Middle Name:DAHL
Last Name:EDMON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:KATRINA
Other - Middle Name:DAHL
Other - Last Name:WILBURN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4285 N RANCHO DR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89130-3446
Mailing Address - Country:US
Mailing Address - Phone:702-385-5331
Mailing Address - Fax:
Practice Address - Street 1:4285 N RANCHO DR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89130-3446
Practice Address - Country:US
Practice Address - Phone:702-385-5331
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-17
Last Update Date:2019-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X, 225400000X
MI6801097572101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner