Provider Demographics
NPI:1780311316
Name:FAULKENBERRY, KENNEDY BREA
Entity type:Individual
Prefix:
First Name:KENNEDY
Middle Name:BREA
Last Name:FAULKENBERRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KENNEDY
Other - Middle Name:BREA
Other - Last Name:BLUE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:154 YARBOROUGH AVE
Mailing Address - Street 2:
Mailing Address - City:ASHDOWN
Mailing Address - State:AR
Mailing Address - Zip Code:71822-8446
Mailing Address - Country:US
Mailing Address - Phone:870-200-5062
Mailing Address - Fax:
Practice Address - Street 1:1710 MOORES LN
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-1858
Practice Address - Country:US
Practice Address - Phone:903-794-2705
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-03
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
235Z00000X
AR201971235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist