Provider Demographics
NPI:1801374038
Name:EDMOND, CHERYL (CASAC)
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:
Last Name:EDMOND
Suffix:
Gender:F
Credentials:CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2976 NORTHERN BLVD
Mailing Address - Street 2:
Mailing Address - City:LONG ISLAND CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11101-2822
Mailing Address - Country:US
Mailing Address - Phone:347-510-3643
Mailing Address - Fax:
Practice Address - Street 1:1523 JARVIS AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-5604
Practice Address - Country:US
Practice Address - Phone:347-880-6466
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-31
Last Update Date:2018-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY17787101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)