Provider Demographics
NPI:1174374987
Name:KINKEAD, TANYA LYNN ANN (PLPC)
Entity type:Individual
Prefix:MRS
First Name:TANYA
Middle Name:LYNN ANN
Last Name:KINKEAD
Suffix:
Gender:F
Credentials:PLPC
Other - Prefix:
Other - First Name:TANYA
Other - Middle Name:LYNN ANN
Other - Last Name:GABEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:402 S SILVER SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63703-7536
Mailing Address - Country:US
Mailing Address - Phone:573-334-1100
Mailing Address - Fax:
Practice Address - Street 1:309 GARRETT ST
Practice Address - Street 2:
Practice Address - City:FREDERICKTOWN
Practice Address - State:MO
Practice Address - Zip Code:63645-1084
Practice Address - Country:US
Practice Address - Phone:573-783-4104
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-29
Last Update Date:2024-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023050856101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO490139105Medicaid