Healthcare Provider Details

I. General information

NPI: 1386505048
Provider Name (Legal Business Name): TAILGATE TIME INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2025
Last Update Date: 11/21/2025
Certification Date: 11/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

778 COUNTY ROAD 680
BAY AR
72411-9300
US

IV. Provider business mailing address

778 COUNTY ROAD 680
BAY AR
72411-9300
US

V. Phone/Fax

Practice location:
  • Phone: 901-832-3050
  • Fax:
Mailing address:
  • Phone: 901-832-3050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: AMANDA MICHELLE BARKER
Title or Position: CO-FOUNDER/CLINICAL DIRECTOR
Credential: LPC
Phone: 901-832-3050