Provider Demographics
NPI:1265564645
Name:EDMONDSON, LISA MAY (LCSW)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:MAY
Last Name:EDMONDSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 ARBOR RIDGE CT
Mailing Address - Street 2:
Mailing Address - City:KNIGHTDALE
Mailing Address - State:NC
Mailing Address - Zip Code:27545-9202
Mailing Address - Country:US
Mailing Address - Phone:919-210-4176
Mailing Address - Fax:877-757-4728
Practice Address - Street 1:106 N 1ST AVE
Practice Address - Street 2:SUITE A
Practice Address - City:KNIGHTDALE
Practice Address - State:NC
Practice Address - Zip Code:27545-8093
Practice Address - Country:US
Practice Address - Phone:919-210-4176
Practice Address - Fax:877-757-4728
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2015-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0056081041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6106593Medicaid
NC2852410Medicare PIN