Provider Demographics
NPI:1336217256
Name:EDWARDS, KATIE CELISE (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:CELISE
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:CELISE
Other - Last Name:EDWARDS-MARTINEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:812 JEFFERSON STREET NORTHEAST
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110
Mailing Address - Country:US
Mailing Address - Phone:505-463-3276
Mailing Address - Fax:
Practice Address - Street 1:812 JEFFERSON ST NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-6206
Practice Address - Country:US
Practice Address - Phone:505-463-3276
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2011-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2606235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM00067332Medicaid