Provider Demographics
NPI:1346588506
Name:EDWARDSON, WALTER JOHN
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:JOHN
Last Name:EDWARDSON
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 1:618 W GREEN ST
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:MI
Mailing Address - Zip Code:49068-1428
Mailing Address - Country:US
Mailing Address - Phone:269-274-3844
Mailing Address - Fax:
Practice Address - Street 1:585 MACK BAYOU RD
Practice Address - Street 2:
Practice Address - City:SANTA ROSA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32459-3111
Practice Address - Country:US
Practice Address - Phone:850-213-4595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-23
Last Update Date:2018-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101000203235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist