Provider Demographics
NPI:1114394285
Name:TRACY TULLOS SOUTHERN THERAPY SPECIALISTS
Entity Type:Organization
Organization Name:TRACY TULLOS SOUTHERN THERAPY SPECIALISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:
Authorized Official - Last Name:TULLOS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:479-576-2799
Mailing Address - Street 1:PO BOX 9178
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72811-9178
Mailing Address - Country:US
Mailing Address - Phone:479-498-6750
Mailing Address - Fax:479-968-1673
Practice Address - Street 1:701 E MAIN ST
Practice Address - Street 2:SUITE 2
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72801-5247
Practice Address - Country:US
Practice Address - Phone:479-576-2799
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-25
Last Update Date:2015-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty