Provider Demographics
NPI:1154826592
Name:EDMONSON, ELIZABETH MUNRO (BS)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:MUNRO
Last Name:EDMONSON
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3601 E WYOMING AVE SPC 474
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89104-4945
Mailing Address - Country:US
Mailing Address - Phone:702-544-9188
Mailing Address - Fax:
Practice Address - Street 1:5120 S PECOS RD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89120-1299
Practice Address - Country:US
Practice Address - Phone:702-560-5973
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-28
Last Update Date:2018-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV101YM800XMedicaid