Provider Demographics
NPI:1619227279
Name:KENNEDY, TRACY ANN (LPC)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:ANN
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1848
Mailing Address - Street 2:
Mailing Address - City:MENA
Mailing Address - State:AR
Mailing Address - Zip Code:71953-1841
Mailing Address - Country:US
Mailing Address - Phone:479-437-3449
Mailing Address - Fax:479-243-0285
Practice Address - Street 1:139 SCHOOL LN
Practice Address - Street 2:
Practice Address - City:MENA
Practice Address - State:AR
Practice Address - Zip Code:71953-8432
Practice Address - Country:US
Practice Address - Phone:479-394-2932
Practice Address - Fax:479-243-0285
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-11
Last Update Date:2019-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARP1901004101YP2500X
ARA1611145101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional