Basic Information
| Provider Information | |||||||||
| NPI: | 1518588102 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EDMONDS | ||||||||
| FirstName: | MARISA | ||||||||
| MiddleName: | MARGARET | ||||||||
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| Credential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 527 N MAPLE ST | ||||||||
| Address2: | |||||||||
| City: | MURFREESBORO | ||||||||
| State: | TN | ||||||||
| PostalCode: | 371302833 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6155644984 | ||||||||
| FaxNumber: | 8778666752 | ||||||||
| Practice Location | |||||||||
| Address1: | 527 N MAPLE ST | ||||||||
| Address2: | |||||||||
| City: | MURFREESBORO | ||||||||
| State: | TN | ||||||||
| PostalCode: | 371302833 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6155644984 | ||||||||
| FaxNumber: | 8778666752 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2020 | ||||||||
| LastUpdateDate: | 06/14/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | N | 103K00000X | 1-20-42544 | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.