Provider Demographics
NPI:1598505257
Name:EDWARDS, SUSAN CAMILLE (HIS)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:CAMILLE
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:HIS
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:CAMILLE
Other - Last Name:BIVENS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CPHT
Mailing Address - Street 1:1051 JONES BLVD
Mailing Address - Street 2:
Mailing Address - City:MILAN
Mailing Address - State:TN
Mailing Address - Zip Code:38358-6193
Mailing Address - Country:US
Mailing Address - Phone:731-388-3669
Mailing Address - Fax:
Practice Address - Street 1:1051 JONES BLVD
Practice Address - Street 2:
Practice Address - City:MILAN
Practice Address - State:TN
Practice Address - Zip Code:38358-6193
Practice Address - Country:US
Practice Address - Phone:731-388-3669
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-30
Last Update Date:2024-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000001080237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist