Provider Demographics
NPI:1699953976
Name:EDWARDS, LANA MARIE (MS CCCSLP)
Entity type:Individual
Prefix:MRS
First Name:LANA
Middle Name:MARIE
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:MS CCCSLP
Other - Prefix:MISS
Other - First Name:LANA
Other - Middle Name:MARIE
Other - Last Name:BRICKWELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS CCCSLP
Mailing Address - Street 1:PO BOX 564
Mailing Address - Street 2:626 EAST SLIFER STREET
Mailing Address - City:PORTAGE
Mailing Address - State:WI
Mailing Address - Zip Code:53901
Mailing Address - Country:US
Mailing Address - Phone:608-742-8814
Mailing Address - Fax:608-742-2384
Practice Address - Street 1:626 EAST SLIFER STREET
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:WI
Practice Address - Zip Code:53901
Practice Address - Country:US
Practice Address - Phone:608-742-8814
Practice Address - Fax:608-742-2384
Is Sole Proprietor?:No
Enumeration Date:2008-02-08
Last Update Date:2008-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2127154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42787700Medicaid