Provider Demographics
NPI:1306240981
Name:DODD, ELIZABETH ANN (CCC-SLP)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ANN
Last Name:DODD
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7541
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37664-7541
Mailing Address - Country:US
Mailing Address - Phone:423-360-7228
Mailing Address - Fax:
Practice Address - Street 1:4527 HARBOR DR
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37664-2921
Practice Address - Country:US
Practice Address - Phone:423-360-7228
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-10
Last Update Date:2014-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202000541235Z00000X
TNSP 0000000325235Z00000X
IA074463235Z00000X
TX110728235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNSP 0000000325OtherDIVISION OF HEALTH RELATED BOARDS
VA2202000541OtherBOARD OF AUDIOLOGY & SPEECH-LANGUAGE PATHOLOGY
TX110728OtherSTATE BOARD OF EXAMINERS FOR SPEECH-LANGUAGE PATHOLOGY & AUDIOLOGY
IA074463OtherBOARD OF SPEECH PATHOLOGY & AUDIOLOGY