Provider Demographics
NPI:1912159831
Name:KINLEY, NICKI SHAUNTEL (LCSW)
Entity Type:Individual
Prefix:
First Name:NICKI
Middle Name:SHAUNTEL
Last Name:KINLEY
Suffix:
Gender:F
Credentials:LCSW
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 277
Mailing Address - Street 2:
Mailing Address - City:BRYANT
Mailing Address - State:AR
Mailing Address - Zip Code:72089-0277
Mailing Address - Country:US
Mailing Address - Phone:501-350-9660
Mailing Address - Fax:501-847-6905
Practice Address - Street 1:209 ROYA LN STE 4
Practice Address - Street 2:
Practice Address - City:BRYANT
Practice Address - State:AR
Practice Address - Zip Code:72022-2669
Practice Address - Country:US
Practice Address - Phone:501-350-9660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-22
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2390-C104100000X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial Worker