Healthcare Provider Details

I. General information

NPI: 1598889552
Provider Name (Legal Business Name): LAMARR D. EDGERSON LMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 06/19/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7001 PROSPECT PL NE
ALBUQUERQUE NM
87110-4311
US

IV. Provider business mailing address

8044 WATERBURY AVE NW
ALBUQUERQUE NM
87120-5525
US

V. Phone/Fax

Practice location:
  • Phone: 505-629-1590
  • Fax:
Mailing address:
  • Phone: 505-629-1590
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number0112671
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: