Provider Demographics
NPI:1710492624
Name:EDMOND, AALIYAH MICHELLE
Entity Type:Individual
Prefix:
First Name:AALIYAH
Middle Name:MICHELLE
Last Name:EDMOND
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7835 LONGHORN CIR E
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32244-7070
Mailing Address - Country:US
Mailing Address - Phone:863-529-7145
Mailing Address - Fax:
Practice Address - Street 1:1563 KINGSLEY AVE STE 103
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-4503
Practice Address - Country:US
Practice Address - Phone:904-602-9740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-14
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician