Provider Demographics
NPI:1093169690
Name:EDGERTON, SHELLEY BONIN (LPC)
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:BONIN
Last Name:EDGERTON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12147 COURSEY BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-4410
Mailing Address - Country:US
Mailing Address - Phone:225-771-8849
Mailing Address - Fax:225-771-8876
Practice Address - Street 1:12147 COURSEY BLVD STE B
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70816-4410
Practice Address - Country:US
Practice Address - Phone:225-771-8849
Practice Address - Fax:225-771-8876
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-20
Last Update Date:2016-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA4643101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional