Provider Demographics
NPI:1467503896
Name:ROBERTS, KHANEDRA EDWARDS (MS,CCC-SLP)
Entity type:Individual
Prefix:MS
First Name:KHANEDRA
Middle Name:EDWARDS
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:MS,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:PO BOX 812
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:IN
Mailing Address - Zip Code:46368-0812
Mailing Address - Country:US
Mailing Address - Phone:219-331-9514
Mailing Address - Fax:219-939-0020
Practice Address - Street 1:2812 CUMBERLAND DR APT 1G
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-2532
Practice Address - Country:US
Practice Address - Phone:219-331-9514
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-14
Last Update Date:2020-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22003661A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200726320OtherSPEECH PATHOLOGIST
IN200340020AMedicaid