Provider Demographics
NPI:1548647662
Name:ANDRADA, EDGAR
Entity type:Individual
Prefix:
First Name:EDGAR
Middle Name:
Last Name:ANDRADA
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 1:11610 NW STONE MOUNTAIN LN APT 208
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97229-5995
Mailing Address - Country:US
Mailing Address - Phone:971-202-6833
Mailing Address - Fax:
Practice Address - Street 1:11610 NW STONE MOUNTAIN LN APT 208
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97229-5995
Practice Address - Country:US
Practice Address - Phone:971-202-6833
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-27
Last Update Date:2015-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3838111101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health