Provider Demographics
NPI:1396885539
Name:EDMONDSON, EVELYN CRAIG (LCSW)
Entity type:Individual
Prefix:MRS
First Name:EVELYN
Middle Name:CRAIG
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:PO BOX 1689
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:GA
Mailing Address - Zip Code:30525-0043
Mailing Address - Country:US
Mailing Address - Phone:706-782-0717
Mailing Address - Fax:706-782-5266
Practice Address - Street 1:44 COTTONWOOD STREET
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:GA
Practice Address - Zip Code:30525
Practice Address - Country:US
Practice Address - Phone:706-782-0717
Practice Address - Fax:706-782-5266
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0009241041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA10045590OtherAMERIGROUP
GA10045590OtherAMERIGROUP