Provider Demographics
NPI:1063249704
Name:EDINGER, MARY SOUTHGATE CLAY
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:SOUTHGATE CLAY
Last Name:EDINGER
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 1:633 UPLAND RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40206-2836
Mailing Address - Country:US
Mailing Address - Phone:502-593-2618
Mailing Address - Fax:
Practice Address - Street 1:130 FAIRFAX AVE LOWR LEVELC
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4939
Practice Address - Country:US
Practice Address - Phone:502-593-2618
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-17
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY293649106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist