Healthcare Provider Details

I. General information

NPI: 1447981584
Provider Name (Legal Business Name): MARY ELIZABETH KENNEDY PSYD, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2022
Last Update Date: 10/07/2024
Certification Date: 10/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 FORT ROOTS DR
NORTH LITTLE ROCK AR
72114-1709
US

IV. Provider business mailing address

5800 ROPE TRL
JACKSONVILLE AR
72076-6252
US

V. Phone/Fax

Practice location:
  • Phone: 501-257-1417
  • Fax:
Mailing address:
  • Phone: 318-232-2318
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number86820
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6352000610
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: