Provider Demographics
NPI:1881640712
Name:TULLOCK, ELIZABETH JEAN (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:JEAN
Last Name:TULLOCK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:201 W SPRINGDALE AVE
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37917-5158
Mailing Address - Country:US
Mailing Address - Phone:865-329-9124
Mailing Address - Fax:865-541-6942
Practice Address - Street 1:6055 SHALLOWFORD RD
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421
Practice Address - Country:US
Practice Address - Phone:423-266-6751
Practice Address - Fax:423-763-4662
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2018-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN12131041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3711666Medicare ID - Type Unspecified