Provider Demographics
NPI:1275019564
Name:EDGE, SHELBY PATRICK (MS, CF-SLP)
Entity Type:Individual
Prefix:
First Name:SHELBY
Middle Name:PATRICK
Last Name:EDGE
Suffix:
Gender:F
Credentials:MS, CF-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:290 ALUMNI DR STE 104
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40503-1601
Mailing Address - Country:US
Mailing Address - Phone:859-218-2322
Mailing Address - Fax:859-257-0284
Practice Address - Street 1:290 ALUMNI DR STE 104
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-1601
Practice Address - Country:US
Practice Address - Phone:859-218-2322
Practice Address - Fax:859-257-0284
Is Sole Proprietor?:No
Enumeration Date:2018-07-19
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY242922235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY242922OtherINTERIM LICENSE