Provider Demographics
NPI:1891185799
Name:EDMONSON, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:EDMONSON
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 1:46 CEDAR ROAD
Mailing Address - Street 2:
Mailing Address - City:SHREWSBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01545
Mailing Address - Country:US
Mailing Address - Phone:214-763-9662
Mailing Address - Fax:
Practice Address - Street 1:46 CEDAR RD
Practice Address - Street 2:
Practice Address - City:SHREWSBURY
Practice Address - State:MA
Practice Address - Zip Code:01545-4401
Practice Address - Country:US
Practice Address - Phone:214-763-9662
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-29
Last Update Date:2015-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1-14-16054103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst