Provider Demographics
NPI:1639132780
Name:ST JOHN EDDS, MARY SUSAN (LSCSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:SUSAN
Last Name:ST JOHN EDDS
Suffix:
Gender:F
Credentials:LSCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5401 SW 7TH ST
Mailing Address - Street 2:
Mailing Address - City:TOPEKA
Mailing Address - State:KS
Mailing Address - Zip Code:66606-2330
Mailing Address - Country:US
Mailing Address - Phone:785-273-2252
Mailing Address - Fax:
Practice Address - Street 1:330 SW OAKLEY AVE
Practice Address - Street 2:
Practice Address - City:TOPEKA
Practice Address - State:KS
Practice Address - Zip Code:66606-1995
Practice Address - Country:US
Practice Address - Phone:785-273-2252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2013-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS10271041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSR75976Medicare UPIN
010145Medicare ID - Type Unspecified