Healthcare Provider Details

I. General information

NPI: 1861812034
Provider Name (Legal Business Name): DEIDRA EDISON M.ED.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/25/2014
Last Update Date: 03/05/2024
Certification Date: 03/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 C CT
ASHTABULA OH
44004-4577
US

IV. Provider business mailing address

2801 C CT
ASHTABULA OH
44004-4577
US

V. Phone/Fax

Practice location:
  • Phone: 440-998-0722
  • Fax:
Mailing address:
  • Phone: 440-998-0722
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License NumberOH3127884
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: