Provider Demographics
NPI:1093429854
Name:MONDESIR, EDWIDGE (CASAC)
Entity Type:Individual
Prefix:MS
First Name:EDWIDGE
Middle Name:
Last Name:MONDESIR
Suffix:
Gender:F
Credentials:CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:870 SAINT NICHOLAS AVE APT F1
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-5273
Mailing Address - Country:US
Mailing Address - Phone:646-479-2375
Mailing Address - Fax:
Practice Address - Street 1:1007 QUENTIN RD
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11223-2341
Practice Address - Country:US
Practice Address - Phone:718-998-3235
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-06
Last Update Date:2023-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
NY38179104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY104100000XMedicaid