Provider Demographics
NPI:1013461466
Name:KIRKENDOLL, TYNIESHA
Entity Type:Individual
Prefix:
First Name:TYNIESHA
Middle Name:
Last Name:KIRKENDOLL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9809 SMOKEFEATHER LN
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75243-2033
Mailing Address - Country:US
Mailing Address - Phone:940-231-7954
Mailing Address - Fax:
Practice Address - Street 1:2770 MAIN ST
Practice Address - Street 2:142
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75033-4302
Practice Address - Country:US
Practice Address - Phone:972-704-1372
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-14
Last Update Date:2016-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX69836101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional