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General NPI Number Information
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NPI Number | 1861688384
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Entity Type | Individual
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Provider Name | NATHAN JOHN EDMUNDSON PSYD
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Gender | Male
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Dates
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Enumeration Date | 09/18/2007
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Last Update Date | 07/20/2018
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Provider Practice Location Address
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Address Line | 118 E DEL RAY AVE
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City | ALEXANDRIA
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State | VA
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Zip | 22301
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Country | US
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Telephone | 703-348-6427
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Fax |
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Provider Business Mailing Address
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Address Line | 306 1/2 E DEL RAY AVE
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City | ALEXANDRIA
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State | VA
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Zip | 22301-1234
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Country | US
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Telephone | 626-665-7582
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 0004017
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License Number State | CO
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Taxonomy #2
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | PSY29380
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License Number State | CA
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Taxonomy #3
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 0810005996
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License Number State | VA
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