Provider Demographics
NPI:1851711451
Name:ROCKWELL, KATHLEEN ELAM (SPEECH AND LANGUAGE)
Entity Type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:ELAM
Last Name:ROCKWELL
Suffix:
Gender:F
Credentials:SPEECH AND LANGUAGE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1917 POWDERHORN PASS CT
Mailing Address - Street 2:
Mailing Address - City:WILDWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63011-1717
Mailing Address - Country:US
Mailing Address - Phone:636-236-7806
Mailing Address - Fax:
Practice Address - Street 1:1917 POWDERHORN PASS CT
Practice Address - Street 2:
Practice Address - City:BALLWIN
Practice Address - State:MO
Practice Address - Zip Code:63011-1717
Practice Address - Country:US
Practice Address - Phone:636-236-7806
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-22
Last Update Date:2014-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOM461666505235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOM461666505OtherMO HEALTHNET NATIONAL PROVIDER IDENTIFIER