Provider Demographics
NPI:1184857369
Name:MOSHER, KENYON MARK (LPC, LADAC)
Entity type:Individual
Prefix:MR
First Name:KENYON
Middle Name:MARK
Last Name:MOSHER
Suffix:
Gender:M
Credentials:LPC, LADAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2503 PINE ST STE 4
Mailing Address - Street 2:
Mailing Address - City:ARKADELPHIA
Mailing Address - State:AR
Mailing Address - Zip Code:71923-4368
Mailing Address - Country:US
Mailing Address - Phone:870-403-3769
Mailing Address - Fax:877-276-1301
Practice Address - Street 1:2503 PINE ST STE 4
Practice Address - Street 2:
Practice Address - City:ARKADELPHIA
Practice Address - State:AR
Practice Address - Zip Code:71923-4368
Practice Address - Country:US
Practice Address - Phone:870-403-3769
Practice Address - Fax:877-276-1301
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-03
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARP110604101YM0800X
ARP1106034101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR231767719Medicaid
NONEOtherNONE