Provider Demographics
NPI:1942755566
Name:EDMONSON, MARY SUZANNE (LOT, LMT)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:SUZANNE
Last Name:EDMONSON
Suffix:
Gender:F
Credentials:LOT, LMT
Other - Prefix:MRS
Other - First Name:M.
Other - Middle Name:SUZANNE
Other - Last Name:EDMONSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LOT, LMT
Mailing Address - Street 1:2116 TAMWORTH CT
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76021-5329
Mailing Address - Country:US
Mailing Address - Phone:817-996-9961
Mailing Address - Fax:
Practice Address - Street 1:2260 POOL RD
Practice Address - Street 2:
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-4278
Practice Address - Country:US
Practice Address - Phone:817-416-7475
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-24
Last Update Date:2016-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX109243225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist