Provider Demographics
NPI:1942523253
Name:EDMONDSON, STEPHANIE JO (LPC-MHSP)
Entity Type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:JO
Last Name:EDMONDSON
Suffix:
Gender:F
Credentials:LPC-MHSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4101 E PIERCE ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85008-6413
Mailing Address - Country:US
Mailing Address - Phone:423-284-5926
Mailing Address - Fax:866-583-8017
Practice Address - Street 1:4101 E PIERCE ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85008-6413
Practice Address - Country:US
Practice Address - Phone:423-284-5926
Practice Address - Fax:866-583-8017
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-02
Last Update Date:2022-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLPC0000002470101YP2500X
TN2470101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
259422OtherNATIONAL CERTIFICATION
TNQ001722Medicaid