Provider Demographics
NPI:1639503246
Name:EDGERLY, DENNIS WAYNE
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:WAYNE
Last Name:EDGERLY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28199 SCOTT MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:SWEET HOME
Mailing Address - State:OR
Mailing Address - Zip Code:97386-9729
Mailing Address - Country:US
Mailing Address - Phone:541-405-6198
Mailing Address - Fax:
Practice Address - Street 1:28199 SCOTT MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:SWEET HOME
Practice Address - State:OR
Practice Address - Zip Code:97386-9729
Practice Address - Country:US
Practice Address - Phone:541-405-6198
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-30
Last Update Date:2013-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst