Provider Demographics
NPI:1942404736
Name:KIRKWOOD, ELIZABETH SOUTHARD (MS,CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:SOUTHARD
Last Name:KIRKWOOD
Suffix:
Gender:F
Credentials:MS,CCC-SLP
Other - Prefix:MRS
Other - First Name:BETH
Other - Middle Name:S
Other - Last Name:KIRKWOOD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2700 STANLEY GAULT PKWY STE 129
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-5176
Mailing Address - Country:US
Mailing Address - Phone:270-326-3949
Mailing Address - Fax:270-326-3954
Practice Address - Street 1:900 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:MADISONVILLE
Practice Address - State:KY
Practice Address - Zip Code:42431-1644
Practice Address - Country:US
Practice Address - Phone:270-825-5246
Practice Address - Fax:270-825-5497
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-13
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2894235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100471320Medicaid
KY000000592974OtherBSBS
KY00503050Medicare PIN