Basic Information
| Provider Information | |||||||||
| NPI: | 1114442316 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EDGERLY | ||||||||
| FirstName: | BENNETT | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D., LPC | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2920 N 4TH ST | ||||||||
| Address2: | |||||||||
| City: | FLAGSTAFF | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 860041816 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9285229400 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2920 N 4TH ST | ||||||||
| Address2: | |||||||||
| City: | FLAGSTAFF | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 860041816 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9285229400 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2017 | ||||||||
| LastUpdateDate: | 08/08/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | LPC-15364 | AZ | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | LPC-15634 | 01 | AZ | ARIZONA LICENSE | OTHER |