Provider Demographics
NPI:1891411559
Name:TRACY KENNEDY COUNSELING LLC
Entity Type:Organization
Organization Name:TRACY KENNEDY COUNSELING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:
Authorized Official - Last Name:KENNEDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-216-4262
Mailing Address - Street 1:151 ALLEN LN
Mailing Address - Street 2:
Mailing Address - City:ODEN
Mailing Address - State:AR
Mailing Address - Zip Code:71961-8069
Mailing Address - Country:US
Mailing Address - Phone:479-216-4262
Mailing Address - Fax:
Practice Address - Street 1:1142 HIGHWAY 71 S STE C
Practice Address - Street 2:
Practice Address - City:MENA
Practice Address - State:AR
Practice Address - Zip Code:71953-8078
Practice Address - Country:US
Practice Address - Phone:479-437-7967
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-14
Last Update Date:2022-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty