Provider Demographics
NPI:1720628951
Name:EDMONDSON, MATT DAVID
Entity Type:Individual
Prefix:
First Name:MATT
Middle Name:DAVID
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:PO BOX 3218
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93385-3218
Mailing Address - Country:US
Mailing Address - Phone:661-869-1795
Mailing Address - Fax:661-869-7194
Practice Address - Street 1:708 LINCOLN ST
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93305-3711
Practice Address - Country:US
Practice Address - Phone:661-869-1795
Practice Address - Fax:661-869-1764
Is Sole Proprietor?:No
Enumeration Date:2020-01-15
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARADT101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)