Provider Demographics
NPI:1518587690
Name:PAQUITA R PULLEN, LLC
Entity Type:Organization
Organization Name:PAQUITA R PULLEN, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:
Authorized Official - First Name:PAQUITA
Authorized Official - Middle Name:R
Authorized Official - Last Name:PULLEN
Authorized Official - Suffix:
Authorized Official - Credentials:LPC-MHSP
Authorized Official - Phone:615-424-7908
Mailing Address - Street 1:110 GLANCY ST STE 203
Mailing Address - Street 2:
Mailing Address - City:GOODLETTSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37072-2313
Mailing Address - Country:US
Mailing Address - Phone:615-424-7908
Mailing Address - Fax:
Practice Address - Street 1:110 GLANCY ST STE 203
Practice Address - Street 2:
Practice Address - City:GOODLETTSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37072-2313
Practice Address - Country:US
Practice Address - Phone:615-424-7908
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-20
Last Update Date:2020-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN146773351Medicaid