Basic Information
| Provider Information | |||||||||
| NPI: | 1376898619 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TERRY | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | BETH | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MA, LPC-I | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | EDGERLY | ||||||||
| OtherFirstName: | AMY | ||||||||
| OtherMiddleName: | BETH | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 58646 MCNUTTY WAY | ||||||||
| Address2: | |||||||||
| City: | ST. HELENS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033975211 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 58646 MCNUTTY WAY | ||||||||
| Address2: | |||||||||
| City: | ST. HELENS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033975211 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2012 | ||||||||
| LastUpdateDate: | 02/08/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.