Provider Demographics
NPI:1790446995
Name:TOLBERT, KENNY J
Entity Type:Individual
Prefix:
First Name:KENNY
Middle Name:J
Last Name:TOLBERT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7255 MEESHOW DR STE A
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72762-5269
Mailing Address - Country:US
Mailing Address - Phone:479-306-4480
Mailing Address - Fax:
Practice Address - Street 1:7255 MEESHOW DR STE A
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72762-5269
Practice Address - Country:US
Practice Address - Phone:479-306-4480
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-10
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)