Provider Demographics
NPI:1033923610
Name:EDGE, AUSTIN
Entity type:Individual
Prefix:
First Name:AUSTIN
Middle Name:
Last Name:EDGE
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 1:18333 BOTHELL WAY NE APT 420
Mailing Address - Street 2:
Mailing Address - City:BOTHELL
Mailing Address - State:WA
Mailing Address - Zip Code:98011-1943
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18333 BOTHELL WAY NE APT 420
Practice Address - Street 2:
Practice Address - City:BOTHELL
Practice Address - State:WA
Practice Address - Zip Code:98011-1943
Practice Address - Country:US
Practice Address - Phone:206-948-5025
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-04
Last Update Date:2025-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALF00001767106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist