MEDICARE: TAMMY C KENNEDY LPC, LADAC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	P0006017	AR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5Y674	OTHER	AR	AR BLUE SHIELD PROVIDER #

General Provider Information

NPI Number	:	1932138278
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TAMMY C KENNEDY LPC, LADAC

Provider Business Mailing Address
First Line	:	5311 S STONE BAY CT
Second Line	:
City	:	ROGERS
State	:	AR
Zip	:	72758-4149
Country	:	US
Telephone Number	:	479-257-5101
Fax Number	:

Provider Business Practice Location Address
First Line	:	5311 S STONE BAY CT
Second Line	:
City	:	ROGERS
State	:	AR
Zip	:	72758-4149
Country	:	US
Telephone Number	:	479-257-5101
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/30/2006
Last Update Date	:	11/13/2020

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