Healthcare Provider Details

I. General information

NPI: 1730544099
Provider Name (Legal Business Name): AARON EDENSHAW LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/30/2015
Last Update Date: 05/25/2021
Certification Date: 05/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

356 OURAY DR #899
IGNACIO CO
81137
US

IV. Provider business mailing address

509 MCDONALD RD
FARMINGTON NM
87401-3583
US

V. Phone/Fax

Practice location:
  • Phone: 970-563-2370
  • Fax: 970-563-0206
Mailing address:
  • Phone: 405-308-2149
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberBBH-LCSW-LIC-16176
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: