Provider Demographics
NPI:1225485345
Name:EDMONTSON, SHAWN (CASAC-T)
Entity Type:Individual
Prefix:MR
First Name:SHAWN
Middle Name:
Last Name:EDMONTSON
Suffix:
Gender:M
Credentials:CASAC-T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 MALCOLM X BLVD
Mailing Address - Street 2:APT. 11J
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10026-3001
Mailing Address - Country:US
Mailing Address - Phone:212-876-2300
Mailing Address - Fax:212-722-7618
Practice Address - Street 1:2367-69 SECOND AVENUE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10035
Practice Address - Country:US
Practice Address - Phone:212-876-2300
Practice Address - Fax:212-722-7618
Is Sole Proprietor?:No
Enumeration Date:2016-05-18
Last Update Date:2016-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY31064101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)