Basic Information
| Provider Information | |||||||||
| NPI: | 1053438325 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EDWARDS | ||||||||
| FirstName: | ROBERTA | ||||||||
| MiddleName: | W | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | SPEECH PATHOLOGIST | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WATKINS | ||||||||
| OtherFirstName: | ROBERTA | ||||||||
| OtherMiddleName: | W | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | SPEECH PATHOLOGIST | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 711 AVIGNON DR | ||||||||
| Address2: | |||||||||
| City: | RIDGELAND | ||||||||
| State: | MS | ||||||||
| PostalCode: | 391575120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6016056777 | ||||||||
| FaxNumber: | 6018135460 | ||||||||
| Practice Location | |||||||||
| Address1: | 4607 LINDBERGH DR | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392093855 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012036378 | ||||||||
| FaxNumber: | 6012036379 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2007 | ||||||||
| LastUpdateDate: | 01/06/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | S2373 | MS | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 07071013 | 05 | MS | MEDICAID |