Provider Demographics
NPI:1174856264
Name:EDIMO, LAURA E (LMSW)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:E
Last Name:EDIMO
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:E
Other - Last Name:RILEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 2000
Mailing Address - Street 2:200 CENTER AVE
Mailing Address - City:MORIARTY
Mailing Address - State:NM
Mailing Address - Zip Code:87035
Mailing Address - Country:US
Mailing Address - Phone:505-832-5817
Mailing Address - Fax:505-328-1354
Practice Address - Street 1:200 CENTER AVE
Practice Address - Street 2:
Practice Address - City:MORIARTY
Practice Address - State:NM
Practice Address - Zip Code:87035
Practice Address - Country:US
Practice Address - Phone:505-832-5817
Practice Address - Fax:505-328-1354
Is Sole Proprietor?:No
Enumeration Date:2009-09-08
Last Update Date:2010-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMX-07066104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker