Healthcare Provider Details

I. General information

NPI: 1134625908
Provider Name (Legal Business Name): JUDITH EDMUNDSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2018
Last Update Date: 08/16/2023
Certification Date: 08/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3624 MARGARET FOWLER CT
CHINO HILLS CA
91709-5456
US

IV. Provider business mailing address

7902 SPRING HILL ST
CHINO CA
91708-7620
US

V. Phone/Fax

Practice location:
  • Phone: 909-740-3133
  • Fax: 909-306-5427
Mailing address:
  • Phone: 909-620-2521
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPCC7946
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPCC7946
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: