Provider Demographics
NPI:1215283718
Name:PAULSON, TRACEE
Entity type:Individual
Prefix:
First Name:TRACEE
Middle Name:
Last Name:PAULSON
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:PO BOX 56050
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72215-6050
Mailing Address - Country:US
Mailing Address - Phone:501-661-0720
Mailing Address - Fax:501-325-7938
Practice Address - Street 1:1600 ALDERSGATE RD
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-6676
Practice Address - Country:US
Practice Address - Phone:501-661-0720
Practice Address - Fax:501-325-7938
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-02
Last Update Date:2017-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2406-C104100000X
1041C0700X
AR2406-C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker