Provider Demographics
NPI:1669827499
Name:PULLEN, CLINTON III
Entity Type:Individual
Prefix:
First Name:CLINTON
Middle Name:
Last Name:PULLEN
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17513 OMEGA CT
Mailing Address - Street 2:
Mailing Address - City:BAKER
Mailing Address - State:LA
Mailing Address - Zip Code:70714-1507
Mailing Address - Country:US
Mailing Address - Phone:225-454-4129
Mailing Address - Fax:
Practice Address - Street 1:17513 OMEGA CT
Practice Address - Street 2:
Practice Address - City:BAKER
Practice Address - State:LA
Practice Address - Zip Code:70714-1507
Practice Address - Country:US
Practice Address - Phone:225-454-4129
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-29
Last Update Date:2016-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor