Provider Demographics
NPI:1265152805
Name:EDGERTON, AUTUM MARIE (SLP)
Entity type:Individual
Prefix:
First Name:AUTUM
Middle Name:MARIE
Last Name:EDGERTON
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1214 SHIPLEY DR
Mailing Address - Street 2:
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-3953
Mailing Address - Country:US
Mailing Address - Phone:910-273-0988
Mailing Address - Fax:
Practice Address - Street 1:151 REGIONS WAY STE A
Practice Address - Street 2:
Practice Address - City:DESTIN
Practice Address - State:FL
Practice Address - Zip Code:32541-5106
Practice Address - Country:US
Practice Address - Phone:850-424-5469
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-01
Last Update Date:2022-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSZ10922235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist