Healthcare Provider Details

I. General information

NPI: 1932138278
Provider Name (Legal Business Name): TAMMY C KENNEDY LPC, LADAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: TAMMY C MCCOLLUM LPC

II. Dates (important events)

Enumeration Date: 06/30/2006
Last Update Date: 11/13/2020
Certification Date: 11/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5311 S STONE BAY CT
ROGERS AR
72758-4149
US

IV. Provider business mailing address

5311 S STONE BAY CT
ROGERS AR
72758-4149
US

V. Phone/Fax

Practice location:
  • Phone: 479-257-5101
  • Fax:
Mailing address:
  • Phone: 479-257-5101
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberP0006017
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: