Basic Information
| Provider Information | |||||||||
| NPI: | 1922018738 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EDWARDS | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | LANE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MA, CCC-SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1011 PROFESSIONAL BLVD | ||||||||
| Address2: | |||||||||
| City: | DALTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 307202506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7062264623 | ||||||||
| FaxNumber: | 7062780580 | ||||||||
| Practice Location | |||||||||
| Address1: | 1011 PROFESSIONAL BLVD | ||||||||
| Address2: | |||||||||
| City: | DALTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 307202506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7062264623 | ||||||||
| FaxNumber: | 7062780580 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 001899 | GA | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 000565133B | 05 | GA | MEDICAID |