Provider Demographics
NPI:1215756234
Name:POULSON, TINA MARIE (DC)
Entity type:Individual
Prefix:DR
First Name:TINA
Middle Name:MARIE
Last Name:POULSON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 E REMINGTON TER
Mailing Address - Street 2:
Mailing Address - City:RAYMORE
Mailing Address - State:MO
Mailing Address - Zip Code:64083-8537
Mailing Address - Country:US
Mailing Address - Phone:816-724-3361
Mailing Address - Fax:
Practice Address - Street 1:302 SE INDEPENDENCE AVE
Practice Address - Street 2:
Practice Address - City:LEES SUMMIT
Practice Address - State:MO
Practice Address - Zip Code:64063-2828
Practice Address - Country:US
Practice Address - Phone:816-867-0992
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-07
Last Update Date:2024-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2024040714111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor