Healthcare Provider Details

I. General information

NPI: 1013575919
Provider Name (Legal Business Name): REGINA EDMONDSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2019
Last Update Date: 08/29/2026
Certification Date: 08/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 MONTROSE WEST AVE
COPLEY OH
44321-3121
US

IV. Provider business mailing address

820 ROSEWOOD DR APT E104
ELYRIA OH
44035-1859
US

V. Phone/Fax

Practice location:
  • Phone: 330-993-4649
  • Fax:
Mailing address:
  • Phone: 440-522-7287
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLICDC-CS.162193
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: