Provider Demographics
NPI:1174817894
Name:EDMONDSON, MARLENA
Entity Type:Individual
Prefix:
First Name:MARLENA
Middle Name:
Last Name:EDMONDSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1186
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47902-1186
Mailing Address - Country:US
Mailing Address - Phone:765-742-4848
Mailing Address - Fax:765-477-9905
Practice Address - Street 1:100 SAW MILL RD STE 3200
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-5597
Practice Address - Country:US
Practice Address - Phone:765-742-4848
Practice Address - Fax:765-477-9905
Is Sole Proprietor?:No
Enumeration Date:2011-05-31
Last Update Date:2011-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical