Basic Information
| Provider Information | |||||||||
| NPI: | 1679157291 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EDGERTON | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | ELIZABETH | ||||||||
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| Credential: | CCC, SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 185 CHARLOIS BLVD | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271031521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367250222 | ||||||||
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| Practice Location | |||||||||
| Address1: | 185 CHARLOIS BLVD | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271031521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367250222 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2021 | ||||||||
| LastUpdateDate: | 04/08/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | N | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 235Z00000X | 30000460 | NC | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 30000460 | 01 | NC | SPEECH LANGUAGE PATHOLOGY | OTHER |