Provider Demographics
NPI:1114442316
Name:EDGERLY, BENNETT (PHD, LPC)
Entity Type:Individual
Prefix:DR
First Name:BENNETT
Middle Name:
Last Name:EDGERLY
Suffix:
Gender:M
Credentials:PHD, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 N 17TH AVE
Mailing Address - Street 2:
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80631-9584
Mailing Address - Country:US
Mailing Address - Phone:970-347-2120
Mailing Address - Fax:
Practice Address - Street 1:1300 N 17TH AVE
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80631-9584
Practice Address - Country:US
Practice Address - Phone:970-347-2120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-08
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COLPC.0016208101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZLPC-15634OtherARIZONA LICENSE
COLPC.0016208OtherSTATE LICENSING BOARD OF COLORADO