Provider Demographics
NPI:1619335502
Name:EDGERLY, WKL (COTA/L)
Entity Type:Individual
Prefix:
First Name:WKL
Middle Name:
Last Name:EDGERLY
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:449 S FITNESS PL
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-6828
Mailing Address - Country:US
Mailing Address - Phone:208-957-6301
Mailing Address - Fax:208-228-0585
Practice Address - Street 1:449 S FITNESS PL
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-6828
Practice Address - Country:US
Practice Address - Phone:208-957-6301
Practice Address - Fax:208-228-0585
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-05
Last Update Date:2016-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDOTA-1121224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant