Provider Demographics
NPI:1871733527
Name:TATE KENNEDY, AUDRA MARLANA (LPC)
Entity type:Individual
Prefix:
First Name:AUDRA
Middle Name:MARLANA
Last Name:TATE KENNEDY
Suffix:
Gender:F
Credentials:LPC
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 493
Mailing Address - Street 2:
Mailing Address - City:WHITWELL
Mailing Address - State:TN
Mailing Address - Zip Code:37397-0493
Mailing Address - Country:US
Mailing Address - Phone:423-421-8733
Mailing Address - Fax:
Practice Address - Street 1:701 CHEROKEE BLVD
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37405-3339
Practice Address - Country:US
Practice Address - Phone:423-421-8733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-20
Last Update Date:2013-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2403101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1529812Medicaid