Provider Demographics
NPI:1861587891
Name:EDGERTON, BRADLY J (PHD, CCC-A)
Entity type:Individual
Prefix:MR
First Name:BRADLY
Middle Name:J
Last Name:EDGERTON
Suffix:
Gender:M
Credentials:PHD, CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1405 SE 164TH AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-9644
Mailing Address - Country:US
Mailing Address - Phone:360-256-4425
Mailing Address - Fax:360-260-7249
Practice Address - Street 1:1405 SE 164TH AVE STE 102
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683-9644
Practice Address - Country:US
Practice Address - Phone:360-256-4425
Practice Address - Fax:360-260-7249
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2014-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALD00001333231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8935297OtherWA CRIME VICTIMS
WA0117625OtherWA DEPT OF L&I
OR182440Medicaid
WA4520896OtherAETNA
WA9059056Medicaid
WA8935297OtherWA CRIME VICTIMS
WA8858913Medicare PIN