Provider Demographics
NPI:1083158463
Name:EDMUNDS, ANDREW
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:EDMUNDS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5541 S EVERETT AVE APT 911
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60637-5071
Mailing Address - Country:US
Mailing Address - Phone:915-329-9617
Mailing Address - Fax:
Practice Address - Street 1:3907 MEDICAL PKWY
Practice Address - Street 2:SUITE 103
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78756-4028
Practice Address - Country:US
Practice Address - Phone:915-329-9617
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-05
Last Update Date:2016-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional