Provider Demographics
NPI:1962700724
Name:EDMISTON, KERLIA SUZANNE (MA)
Entity type:Individual
Prefix:MS
First Name:KERLIA
Middle Name:SUZANNE
Last Name:EDMISTON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9075 BUSHY TAIL AVE #103
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89149
Mailing Address - Country:US
Mailing Address - Phone:951-834-2412
Mailing Address - Fax:
Practice Address - Street 1:6655 W. SAHARA AVE.
Practice Address - Street 2:B200
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89146
Practice Address - Country:US
Practice Address - Phone:702-365-0600
Practice Address - Fax:702-365-0602
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-03
Last Update Date:2011-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health