Provider Demographics
NPI:1932138278
Name:KENNEDY, TAMMY C (LPC, LADAC)
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:C
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:LPC, LADAC
Other - Prefix:
Other - First Name:TAMMY
Other - Middle Name:C
Other - Last Name:MCCOLLUM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC
Mailing Address - Street 1:5311 S STONE BAY CT
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72758-4149
Mailing Address - Country:US
Mailing Address - Phone:479-257-5101
Mailing Address - Fax:
Practice Address - Street 1:5311 S STONE BAY CT
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72758-4149
Practice Address - Country:US
Practice Address - Phone:479-257-5101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-30
Last Update Date:2020-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARP0006017101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5Y674OtherAR BLUE SHIELD PROVIDER #