Healthcare Provider Details

I. General information

NPI: 1184532335
Provider Name (Legal Business Name): SOUTHFORK COUNSELING PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2026
Last Update Date: 08/31/2026
Certification Date: 08/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 HOLT RD
PADUCAH KY
42001-8661
US

IV. Provider business mailing address

427 W JEFFERSON ST
PADUCAH KY
42001-4336
US

V. Phone/Fax

Practice location:
  • Phone: 859-489-7384
  • Fax: 270-558-3257
Mailing address:
  • Phone: 859-489-7384
  • Fax: 270-558-3257

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name: ELMER C MAGGARD
Title or Position: OWNER
Credential: PH.D.
Phone: 859-489-7384