Provider Demographics
NPI:1265047096
Name:EDMONDSON, ERICA MARIE (LMT)
Entity type:Individual
Prefix:
First Name:ERICA
Middle Name:MARIE
Last Name:EDMONDSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:780 NEW BRIDGE RD.
Mailing Address - Street 2:
Mailing Address - City:TEANECK
Mailing Address - State:NJ
Mailing Address - Zip Code:07666
Mailing Address - Country:US
Mailing Address - Phone:646-401-1561
Mailing Address - Fax:
Practice Address - Street 1:780 NEW BRIDGE RD.
Practice Address - Street 2:
Practice Address - City:TEANECK
Practice Address - State:NJ
Practice Address - Zip Code:07666
Practice Address - Country:US
Practice Address - Phone:646-401-1561
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-09
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0294-1225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist