Provider Demographics
NPI:1922018738
Name:EDWARDS, KATHLEEN LANE (MA, CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:LANE
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
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Mailing Address - Street 1:1410 CHATTANOOGA AVE
Mailing Address - Street 2:
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30720-2564
Mailing Address - Country:US
Mailing Address - Phone:706-226-4623
Mailing Address - Fax:706-278-0580
Practice Address - Street 1:1410 CHATTANOOGA AVE
Practice Address - Street 2:
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30720-2564
Practice Address - Country:US
Practice Address - Phone:706-226-4623
Practice Address - Fax:706-278-0580
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2023-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA001899235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000565133BMedicaid