Provider Demographics
NPI:1548906720
Name:EDMISTON, AMANDA JOAN (LSW)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:JOAN
Last Name:EDMISTON
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15072 E GUNNISON PL
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80012-5742
Mailing Address - Country:US
Mailing Address - Phone:319-621-1276
Mailing Address - Fax:
Practice Address - Street 1:1421 S POTOMAC ST
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80012-4535
Practice Address - Country:US
Practice Address - Phone:970-310-3406
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-10
Last Update Date:2022-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCSW.099288161041C0700X
COLSW.0009922847104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker