Provider Demographics
NPI:1164494977
Name:EDMONDS, STEPHEN LERON (MPT)
Entity Type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:LERON
Last Name:EDMONDS
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5308 RIVER EDGE RD
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23502-3509
Mailing Address - Country:US
Mailing Address - Phone:757-971-3464
Mailing Address - Fax:757-423-8298
Practice Address - Street 1:5308 RIVER EDGE RD
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23502-3509
Practice Address - Country:US
Practice Address - Phone:757-971-3464
Practice Address - Fax:757-423-8298
Is Sole Proprietor?:No
Enumeration Date:2006-02-06
Last Update Date:2008-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171WH0202X
VA2305202617225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No171WH0202XOther Service ProvidersContractorHome Modifications