Healthcare Provider Details

I. General information

NPI: 1659203818
Provider Name (Legal Business Name): MALIK EDMONDS LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2026
Last Update Date: 06/02/2026
Certification Date: 06/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2244 EXECUTIVE DR
HAMPTON VA
23666-2430
US

IV. Provider business mailing address

2244 EXECUTIVE DR
HAMPTON VA
23666-2430
US

V. Phone/Fax

Practice location:
  • Phone: 757-315-3617
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904020459
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: