Provider Demographics
NPI:1265553697
Name:EDMERSON, CARMEN T (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:CARMEN
Middle Name:T
Last Name:EDMERSON
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:CARMEN
Other - Middle Name:T
Other - Last Name:GLENN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, CCC-SLP
Mailing Address - Street 1:13220 S 48TH ST
Mailing Address - Street 2:APT.#2035
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85044-5019
Mailing Address - Country:US
Mailing Address - Phone:480-763-6041
Mailing Address - Fax:
Practice Address - Street 1:5656 E. GRANT RD.
Practice Address - Street 2:SUITE 100
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712
Practice Address - Country:US
Practice Address - Phone:520-885-9567
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP4869235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ994386Medicaid