Provider Demographics
NPI:1912573262
Name:MCKINNEY, KAMRYN
Entity type:Individual
Prefix:
First Name:KAMRYN
Middle Name:
Last Name:MCKINNEY
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 1:1707 LINWOOD DR STE D
Mailing Address - Street 2:
Mailing Address - City:PARAGOULD
Mailing Address - State:AR
Mailing Address - Zip Code:72450-5365
Mailing Address - Country:US
Mailing Address - Phone:479-222-1082
Mailing Address - Fax:888-420-0239
Practice Address - Street 1:2920 AMERICAN ST
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72764-6935
Practice Address - Country:US
Practice Address - Phone:479-222-1082
Practice Address - Fax:888-420-0239
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-27
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR12364804103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR299437790Medicaid