Provider Demographics
NPI:1881894806
Name:PASOLD, TRACIE L (PHD)
Entity type:Individual
Prefix:DR
First Name:TRACIE
Middle Name:L
Last Name:PASOLD
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 MARSHALL ST # 512-9
Mailing Address - Street 2:DEPT. OF PEDIATRICS, SECTION OF ADOLESCENT MEDICINE
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72202-3510
Mailing Address - Country:US
Mailing Address - Phone:501-364-1849
Mailing Address - Fax:501-364-6728
Practice Address - Street 1:800 MARSHALL ST # 512-9
Practice Address - Street 2:DEPT. OF PEDIATRICS, SECTION OF ADOLESCENT MEDICINE
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72202-3510
Practice Address - Country:US
Practice Address - Phone:501-364-1849
Practice Address - Fax:501-364-6728
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-18
Last Update Date:2007-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR07-24P103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5A459Medicare PIN