Provider Demographics
NPI:1861688384
Name:EDMUNDSON, NATHAN JOHN (PSYD)
Entity Type:Individual
Prefix:MR
First Name:NATHAN
Middle Name:JOHN
Last Name:EDMUNDSON
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:306 1/2 E DEL RAY AVE
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22301-1234
Mailing Address - Country:US
Mailing Address - Phone:626-665-7582
Mailing Address - Fax:
Practice Address - Street 1:118 E DEL RAY AVE
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22301
Practice Address - Country:US
Practice Address - Phone:703-348-6427
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-18
Last Update Date:2018-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0004017103TC0700X
CAPSY29380103TC0700X
VA0810005996103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO36550264Medicaid