Provider Demographics
NPI:1609345552
Name:EDMONDS, ANTOINETTE
Entity type:Individual
Prefix:
First Name:ANTOINETTE
Middle Name:
Last Name:EDMONDS
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 1:6100 BLUE LAGOON DR STE 400
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33126-2080
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1061 W OAKLAND PARK BLVD
Practice Address - Street 2:
Practice Address - City:WILTON MANORS
Practice Address - State:FL
Practice Address - Zip Code:33311-1600
Practice Address - Country:US
Practice Address - Phone:305-757-0602
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-21
Last Update Date:2018-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH15936101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty