Provider Demographics
NPI:1922475169
Name:EDISON, SHICOLE MONIQUE (MS)
Entity Type:Individual
Prefix:MS
First Name:SHICOLE
Middle Name:MONIQUE
Last Name:EDISON
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6311 SW OAK CLIFF AVE
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-7728
Mailing Address - Country:US
Mailing Address - Phone:580-536-3646
Mailing Address - Fax:
Practice Address - Street 1:1614 NW 47TH ST
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-3208
Practice Address - Country:US
Practice Address - Phone:580-355-6033
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-24
Last Update Date:2015-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2840235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist