Provider Demographics
NPI:1396255576
Name:EDMONDSON, DAVID
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:EDMONDSON
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 1:2706 MONZA DR
Mailing Address - Street 2:
Mailing Address - City:SEBRING
Mailing Address - State:FL
Mailing Address - Zip Code:33872-2008
Mailing Address - Country:US
Mailing Address - Phone:863-368-2870
Mailing Address - Fax:
Practice Address - Street 1:15100 HUTCHISON RD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33625-5513
Practice Address - Country:US
Practice Address - Phone:813-515-4045
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-02
Last Update Date:2017-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL017475600Medicaid