Healthcare Provider Details

I. General information

NPI: 1669814745
Provider Name (Legal Business Name): TYNESHA IVORY LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2013
Last Update Date: 11/08/2024
Certification Date: 11/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 N MISSISSIPPI ST
LITTLE ROCK AR
72207-5851
US

IV. Provider business mailing address

10618 BRECKENRIDGE DR
LITTLE ROCK AR
72211-1802
US

V. Phone/Fax

Practice location:
  • Phone: 501-217-8600
  • Fax:
Mailing address:
  • Phone: 501-217-8600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberA2111000
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateAR
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberP2407019
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: