Provider Demographics
NPI:1902197924
Name:POULSON, VICKIE SUE
Entity Type:Individual
Prefix:
First Name:VICKIE
Middle Name:SUE
Last Name:POULSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:705 S SPRINGFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:GREEN FOREST
Mailing Address - State:AR
Mailing Address - Zip Code:72638-3538
Mailing Address - Country:US
Mailing Address - Phone:870-423-1077
Mailing Address - Fax:870-423-1087
Practice Address - Street 1:1004A S MAIN ST
Practice Address - Street 2:
Practice Address - City:BERRYVILLE
Practice Address - State:AR
Practice Address - Zip Code:72616-4330
Practice Address - Country:US
Practice Address - Phone:870-423-1077
Practice Address - Fax:870-423-1087
Is Sole Proprietor?:No
Enumeration Date:2011-04-25
Last Update Date:2011-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor