Provider Demographics
NPI:1275120248
Name:EDMUNDS, MARA B (MA, EMDR, LMFTA)
Entity Type:Individual
Prefix:
First Name:MARA
Middle Name:B
Last Name:EDMUNDS
Suffix:
Gender:F
Credentials:MA, EMDR, LMFTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1211 S MAIN ST STE 300
Mailing Address - Street 2:
Mailing Address - City:KELLER
Mailing Address - State:TX
Mailing Address - Zip Code:76248-0820
Mailing Address - Country:US
Mailing Address - Phone:254-498-7487
Mailing Address - Fax:
Practice Address - Street 1:1211 S MAIN ST STE 300
Practice Address - Street 2:
Practice Address - City:KELLER
Practice Address - State:TX
Practice Address - Zip Code:76248-0820
Practice Address - Country:US
Practice Address - Phone:817-201-2444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-24
Last Update Date:2020-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX203812106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist