Provider Demographics
NPI:1235218330
Name:EDSON, MARK WERNER (LCSW - R)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:WERNER
Last Name:EDSON
Suffix:
Gender:M
Credentials:LCSW - R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:545 KINGS HWY
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14226-4543
Mailing Address - Country:US
Mailing Address - Phone:716-839-4545
Mailing Address - Fax:
Practice Address - Street 1:2470 WALDEN AVE
Practice Address - Street 2:
Practice Address - City:CHEEKTOWAGA
Practice Address - State:NY
Practice Address - Zip Code:14225-4751
Practice Address - Country:US
Practice Address - Phone:716-681-5718
Practice Address - Fax:716-681-5300
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYPR019181-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000510795001OtherBLUE CROSS / BLUE SHIELD
NYBB7551Medicare ID - Type Unspecified