Provider Demographics
NPI:1982271706
Name:TATE, KENNEDI
Entity type:Individual
Prefix:
First Name:KENNEDI
Middle Name:
Last Name:TATE
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 1:2919 BREEZEWOOD AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28303-5283
Mailing Address - Country:US
Mailing Address - Phone:910-484-1711
Mailing Address - Fax:
Practice Address - Street 1:3550 PARKWOOD BLVD STE 205
Practice Address - Street 2:
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75034-1904
Practice Address - Country:US
Practice Address - Phone:972-521-9060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-09
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst