Provider Demographics
NPI:1689155228
Name:EDMONSON, JOHN
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:EDMONSON
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 1:1350 N GREENVILLE AVE APT 1417
Mailing Address - Street 2:
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75081-2756
Mailing Address - Country:US
Mailing Address - Phone:214-864-2099
Mailing Address - Fax:
Practice Address - Street 1:100 S. TEXAS ST.
Practice Address - Street 2:
Practice Address - City:TIOGA
Practice Address - State:TX
Practice Address - Zip Code:76271
Practice Address - Country:US
Practice Address - Phone:866-656-8384
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-22
Last Update Date:2018-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX66776101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional