Provider Demographics
NPI:1164833034
Name:SOUTHWOOD, BERNETTA (LCSW)
Entity Type:Individual
Prefix:
First Name:BERNETTA
Middle Name:
Last Name:SOUTHWOOD
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 ROCKWOOD LN
Mailing Address - Street 2:
Mailing Address - City:HAZARD
Mailing Address - State:KY
Mailing Address - Zip Code:41701-9415
Mailing Address - Country:US
Mailing Address - Phone:606-436-5761
Mailing Address - Fax:606-436-5797
Practice Address - Street 1:3830 HIGHWAY 15 S
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:KY
Practice Address - Zip Code:41339-8675
Practice Address - Country:US
Practice Address - Phone:606-666-7591
Practice Address - Fax:606-666-8364
Is Sole Proprietor?:No
Enumeration Date:2014-05-14
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2525791041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100454940Medicaid