Provider Demographics
NPI:1841764404
Name:EDMONDS, ANDREW
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:EDMONDS
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 1:3808 ROBERT E LEE DR
Mailing Address - Street 2:
Mailing Address - City:NORTH PRINCE GEORGE
Mailing Address - State:VA
Mailing Address - Zip Code:23860-7522
Mailing Address - Country:US
Mailing Address - Phone:804-324-6507
Mailing Address - Fax:
Practice Address - Street 1:3808 ROBERT E LEE DR
Practice Address - Street 2:
Practice Address - City:NORTH PRINCE GEORGE
Practice Address - State:VA
Practice Address - Zip Code:23860-7522
Practice Address - Country:US
Practice Address - Phone:804-324-6507
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-17
Last Update Date:2019-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA3030Medicaid