MEDICARE: DENNIS WAYNE EDGERLY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1639503246
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DENNIS WAYNE EDGERLY

Provider Business Mailing Address
First Line	:	28199 SCOTT MOUNTAIN RD
Second Line	:
City	:	SWEET HOME
State	:	OR
Zip	:	97386-9729
Country	:	US
Telephone Number	:	541-405-6198
Fax Number	:

Provider Business Practice Location Address
First Line	:	28199 SCOTT MOUNTAIN RD
Second Line	:
City	:	SWEET HOME
State	:	OR
Zip	:	97386-9729
Country	:	US
Telephone Number	:	541-405-6198
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/30/2013
Last Update Date	:	09/05/2013

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Directions to “ DENNIS WAYNE EDGERLY ” Practice Location

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