1033265376 NPI number — MR. WILLARD ELBERT EDMONDSON JR. LICSW

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033265376 NPI number — MR. WILLARD ELBERT EDMONDSON JR. LICSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EDMONDSON
Provider First Name:
WILLARD
Provider Middle Name:
ELBERT
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
LICSW
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
EDMONDSON
Provider Other First Name:
EDDIE
Provider Other Middle Name:
Provider Other Name Prefix Text:
MR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
LICSW
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1033265376
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/03/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
613 19TH AVE E
Provider Second Line Business Mailing Address:
SUITE 102
Provider Business Mailing Address City Name:
SEATTLE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98112-4075
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
206-322-5733
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
613 19TH AVE E
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
SEATTLE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98112-4075
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-322-5733
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/27/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  LW00005212 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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