Provider Demographics
NPI:1497119630
Name:EDMONDSON, MASHAVU (MT)
Entity Type:Individual
Prefix:
First Name:MASHAVU
Middle Name:
Last Name:EDMONDSON
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3683 GARDEN CT
Mailing Address - Street 2:
Mailing Address - City:GROVE CITY
Mailing Address - State:OH
Mailing Address - Zip Code:43123-2906
Mailing Address - Country:US
Mailing Address - Phone:614-801-1307
Mailing Address - Fax:614-801-9095
Practice Address - Street 1:1358A CHERRY BOTTOM RD
Practice Address - Street 2:
Practice Address - City:GAHANNA
Practice Address - State:OH
Practice Address - Zip Code:43230-6771
Practice Address - Country:US
Practice Address - Phone:614-471-2225
Practice Address - Fax:614-471-4260
Is Sole Proprietor?:No
Enumeration Date:2016-04-13
Last Update Date:2016-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH33.017095225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist