Provider Demographics
NPI:1982202198
Name:EDISON, NATHANIEL LEE
Entity Type:Individual
Prefix:
First Name:NATHANIEL
Middle Name:LEE
Last Name:EDISON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14548 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:THORNTON
Mailing Address - State:CO
Mailing Address - Zip Code:80602-7005
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14548 HIGH ST
Practice Address - Street 2:
Practice Address - City:THORNTON
Practice Address - State:CO
Practice Address - Zip Code:80602-7005
Practice Address - Country:US
Practice Address - Phone:941-504-4180
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-12
Last Update Date:2020-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician