Provider Demographics
NPI:1952816068
Name:EDMONDSON, WAYNE JR (MS)
Entity Type:Individual
Prefix:MR
First Name:WAYNE
Middle Name:
Last Name:EDMONDSON
Suffix:JR
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6856 HERRON PL
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45424-1841
Mailing Address - Country:US
Mailing Address - Phone:513-432-8045
Mailing Address - Fax:
Practice Address - Street 1:1785 BIG HILL RD
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45439-2219
Practice Address - Country:US
Practice Address - Phone:937-294-0094
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-12
Last Update Date:2017-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health