Provider Demographics
NPI:1659190304
Name:EDMORIN, ISMAELLE
Entity type:Individual
Prefix:
First Name:ISMAELLE
Middle Name:
Last Name:EDMORIN
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 1:734 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RANDOLPH
Mailing Address - State:MA
Mailing Address - Zip Code:02368-5542
Mailing Address - Country:US
Mailing Address - Phone:857-249-8292
Mailing Address - Fax:
Practice Address - Street 1:103 COMMERCIAL ST STE 2
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02302-3133
Practice Address - Country:US
Practice Address - Phone:508-580-4691
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-09
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst