Healthcare Provider Details

I. General information

NPI: 1003727686
Provider Name (Legal Business Name): KE'NIYAH PHILLIPS LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2026
Last Update Date: 09/14/2026
Certification Date: 09/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3302 E MOORE AVE OFC 5
SEARCY AR
72143-5099
US

IV. Provider business mailing address

350 SALEM RD STE 10
CONWAY AR
72034-7525
US

V. Phone/Fax

Practice location:
  • Phone: 501-230-0130
  • Fax: 501-300-9689
Mailing address:
  • Phone: 501-336-8300
  • Fax: 501-329-6166

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberA2608009
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: