Provider Demographics
NPI:1285169946
Name:EDGAR, BRANDON
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:EDGAR
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 1:107 E MAIN ST STE 2
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97501-6022
Mailing Address - Country:US
Mailing Address - Phone:458-225-0895
Mailing Address - Fax:
Practice Address - Street 1:107 E MAIN ST STE 2
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97501-6022
Practice Address - Country:US
Practice Address - Phone:458-225-0895
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-01
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.011067101YP2500X
ORC4709101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional