Provider Demographics
NPI:1306178173
Name:WALLACE, ELIZABETH KELLER (MA, CFY-SLP)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:KELLER
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MA, CFY-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4200 MARY KNOLL LN
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-2118
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6000 HUNTING RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40222-6308
Practice Address - Country:US
Practice Address - Phone:502-426-1425
Practice Address - Fax:502-426-9256
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-04
Last Update Date:2010-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY09-053235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist