Healthcare Provider Details

I. General information

NPI: 1174396980
Provider Name (Legal Business Name): KA LEGACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2023
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 W FLEEMAN
MANILA AR
72442
US

IV. Provider business mailing address

103 W FLEEMAN
MANILA AR
72442-9187
US

V. Phone/Fax

Practice location:
  • Phone: 870-919-6585
  • Fax:
Mailing address:
  • Phone: 870-919-6585
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: TONYA TATROE
Title or Position: CEO
Credential: LPC
Phone: 870-919-6585