Provider Demographics
NPI:1871230698
Name:EDWARDS, MADISON TATE (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:TATE
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 POND ST
Mailing Address - Street 2:
Mailing Address - City:ARDEN
Mailing Address - State:NC
Mailing Address - Zip Code:28704-8500
Mailing Address - Country:US
Mailing Address - Phone:828-774-5222
Mailing Address - Fax:
Practice Address - Street 1:1287 NEWSOME ST
Practice Address - Street 2:
Practice Address - City:MOUNT AIRY
Practice Address - State:NC
Practice Address - Zip Code:27030-5439
Practice Address - Country:US
Practice Address - Phone:919-449-4176
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-13
Last Update Date:2022-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2110112235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist