Provider Demographics
NPI:1659116218
Name:EDMONDSON, CASNIQUE
Entity type:Individual
Prefix:
First Name:CASNIQUE
Middle Name:
Last Name:EDMONDSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 MAINE ST APT C3
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94590-5814
Mailing Address - Country:US
Mailing Address - Phone:925-214-7665
Mailing Address - Fax:
Practice Address - Street 1:201 MAINE ST APT C3
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94590-5814
Practice Address - Country:US
Practice Address - Phone:925-214-7665
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-26
Last Update Date:2024-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician