Provider Demographics
NPI:1669408712
Name:CLENDENEN, KATHLEEN ELLEN (LPC, LMFT)
Entity type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:ELLEN
Last Name:CLENDENEN
Suffix:
Gender:F
Credentials:LPC, LMFT
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 731
Mailing Address - Street 2:
Mailing Address - City:SILOAM SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:72761-0731
Mailing Address - Country:US
Mailing Address - Phone:479-238-3950
Mailing Address - Fax:
Practice Address - Street 1:500 S. BROADWAY ST.
Practice Address - Street 2:
Practice Address - City:SILOAM SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:72761-3606
Practice Address - Country:US
Practice Address - Phone:479-238-3950
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-23
Last Update Date:2016-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARP0405018101YP2500X
ARM0408002106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5X992OtherBLUE SHIELD PROVIDER #