MEDICARE: MS. CONNIE C. EDMONDSON MSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	1508	OK

General Provider Information

NPI Number	:	1730199167
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. CONNIE C. EDMONDSON MSW

Provider Business Mailing Address
First Line	:	6801 BROADWAY EXT
Second Line	:	STE 320
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73116-9037
Country	:	US
Telephone Number	:	405-843-1551
Fax Number	:	405-843-1494

Provider Business Practice Location Address
First Line	:	6801 BROADWAY EXT
Second Line	:	STE 320
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73116-9037
Country	:	US
Telephone Number	:	405-843-1551
Fax Number	:	405-843-1494

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/08/2006
Last Update Date	:	10/16/2019

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