Provider Demographics
NPI:1124120712
Name:TULLOS, TRACY L BAXLEY (LCSW)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:L BAXLEY
Last Name:TULLOS
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 1:3106 W 2ND CT
Mailing Address - Street 2:SUITE 1
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72801-4503
Mailing Address - Country:US
Mailing Address - Phone:479-880-5100
Mailing Address - Fax:479-880-5297
Practice Address - Street 1:3106 W 2ND CT
Practice Address - Street 2:SUITE 1
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72801-4503
Practice Address - Country:US
Practice Address - Phone:479-880-5100
Practice Address - Fax:479-880-5297
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2015-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2041C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical