Provider Demographics
NPI:1639458623
Name:PULLIAM, TRACY (LCSW)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:PULLIAM
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1508 878TH ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT PULASKI
Mailing Address - State:IL
Mailing Address - Zip Code:62548-6569
Mailing Address - Country:US
Mailing Address - Phone:217-840-6178
Mailing Address - Fax:217-422-0041
Practice Address - Street 1:1900 E LAKE SHORE DR
Practice Address - Street 2:SUITE 201
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62521-3824
Practice Address - Country:US
Practice Address - Phone:217-422-0027
Practice Address - Fax:217-422-0041
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-09
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490115631041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical