Healthcare Provider Details

I. General information

NPI: 1194655738
Provider Name (Legal Business Name): MR. LERODRICK KENTRELL EDMOND SR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2026
Last Update Date: 05/22/2026
Certification Date: 05/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

609 NAYLOR ST
CARTHAGE MS
39051-3343
US

IV. Provider business mailing address

609 NAYLOR ST
CARTHAGE MS
39051-3343
US

V. Phone/Fax

Practice location:
  • Phone: 769-325-8273
  • Fax:
Mailing address:
  • Phone: 769-325-8273
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: