Provider Demographics
NPI:1316598295
Name:EDMONDSON, DESMOND
Entity Type:Individual
Prefix:
First Name:DESMOND
Middle Name:
Last Name:EDMONDSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3612 CHANCELSORS DR
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20772-8194
Mailing Address - Country:US
Mailing Address - Phone:210-378-1455
Mailing Address - Fax:
Practice Address - Street 1:15518 NORGE CT
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20716-1378
Practice Address - Country:US
Practice Address - Phone:301-750-2629
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-23
Last Update Date:2019-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst