Provider Demographics
NPI:1073043410
Name:EDGE, NORA SOFIA
Entity Type:Individual
Prefix:
First Name:NORA
Middle Name:SOFIA
Last Name:EDGE
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 1:1105 FERN ST SW
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502-5745
Mailing Address - Country:US
Mailing Address - Phone:413-230-8314
Mailing Address - Fax:
Practice Address - Street 1:1730 POTTERY AVE STE 100
Practice Address - Street 2:
Practice Address - City:PORT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98366-2565
Practice Address - Country:US
Practice Address - Phone:360-443-6111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-18
Last Update Date:2017-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARBT-17-31603106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician