Provider Demographics
NPI:1689915605
Name:PENNINGTON, KRISTEL (LADAC, LCDC)
Entity type:Individual
Prefix:
First Name:KRISTEL
Middle Name:
Last Name:PENNINGTON
Suffix:
Gender:F
Credentials:LADAC, LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1220 ADDYBROOK ST
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72032-5838
Mailing Address - Country:US
Mailing Address - Phone:501-428-6978
Mailing Address - Fax:
Practice Address - Street 1:1220 ADDYBROOK ST
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72032-5838
Practice Address - Country:US
Practice Address - Phone:501-428-6978
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-15
Last Update Date:2024-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
NMCAD0190821101YA0400X
TX13678101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR195277795Medicaid