Provider Demographics
NPI:1861812034
Name:EDISON, DEIDRA (MED)
Entity type:Individual
Prefix:
First Name:DEIDRA
Middle Name:
Last Name:EDISON
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2801 C CT
Mailing Address - Street 2:
Mailing Address - City:ASHTABULA
Mailing Address - State:OH
Mailing Address - Zip Code:44004-4577
Mailing Address - Country:US
Mailing Address - Phone:440-998-0722
Mailing Address - Fax:
Practice Address - Street 1:2801 C CT
Practice Address - Street 2:
Practice Address - City:ASHTABULA
Practice Address - State:OH
Practice Address - Zip Code:44004-4577
Practice Address - Country:US
Practice Address - Phone:440-998-0722
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-25
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOH3127884103TS0200X
101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool