Provider Demographics
NPI:1053438325
Name:EDWARDS, ROBERTA W (SPEECH PATHOLOGIST)
Entity type:Individual
Prefix:MRS
First Name:ROBERTA
Middle Name:W
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:SPEECH PATHOLOGIST
Other - Prefix:
Other - First Name:ROBERTA
Other - Middle Name:W
Other - Last Name:WATKINS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:SPEECH PATHOLOGIST
Mailing Address - Street 1:711 AVIGNON DR
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-5120
Mailing Address - Country:US
Mailing Address - Phone:601-605-6777
Mailing Address - Fax:601-813-5460
Practice Address - Street 1:4607 LINDBERGH DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39209-3855
Practice Address - Country:US
Practice Address - Phone:601-203-6378
Practice Address - Fax:601-203-6379
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS2373235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07071013Medicaid