Healthcare Provider Details

I. General information

NPI: 1053155366
Provider Name (Legal Business Name): EDWARD CARMON CAC-I
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2024
Last Update Date: 06/21/2024
Certification Date: 06/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 2ND ST NW # 2N
WASHINGTON DC
20001-2003
US

IV. Provider business mailing address

425 2ND ST NW # 2N
WASHINGTON DC
20001-2003
US

V. Phone/Fax

Practice location:
  • Phone: 202-783-7343
  • Fax: 202-347-5476
Mailing address:
  • Phone: 202-783-7343
  • Fax: 202-347-5476

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCACI1039
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: