Provider Demographics
NPI:1316342728
Name:EDMONDS, LA TRECE
Entity type:Individual
Prefix:
First Name:LA TRECE
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 1:18300 COUNTY ROAD 40
Mailing Address - Street 2:
Mailing Address - City:ROSHARON
Mailing Address - State:TX
Mailing Address - Zip Code:77583-7312
Mailing Address - Country:US
Mailing Address - Phone:281-995-7917
Mailing Address - Fax:
Practice Address - Street 1:18302 COUNTY ROAD 40
Practice Address - Street 2:
Practice Address - City:ROSHARON
Practice Address - State:TX
Practice Address - Zip Code:77583-7312
Practice Address - Country:US
Practice Address - Phone:281-995-7917
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-28
Last Update Date:2014-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities