MEDICARE: EDMONDSON COUNSELING SERVICES, PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	1508	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	448602140002	OTHER	OK	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1447328489
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EDMONDSON COUNSELING SERVICES, PC

Provider Business Mailing Address
First Line	:	5009 N PENNSYLVANIA AVE
Second Line	:	STE. 116
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73112-8887
Country	:	US
Telephone Number	:	405-843-1551
Fax Number	:	405-843-1494

Provider Business Practice Location Address
First Line	:	5009 N PENNSYLVANIA AVE
Second Line	:	STE. 116
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73112-8887
Country	:	US
Telephone Number	:	405-843-1551
Fax Number	:	405-843-1494

Authorized Official
Title or Position	:	LICENSED CLINICAL SOCIAL WORKER
Name	:	MS. CONNIE CUNNINGHAM EDMONDSON
Credential	:	LCSW
Telephone Number	:	405-843-1551

Provider Enumeration Date	:	11/30/2006
Last Update Date	:	06/17/2011

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