Provider Demographics
NPI:1427765510
Name:HESLEY, TRACI
Entity type:Individual
Prefix:
First Name:TRACI
Middle Name:
Last Name:HESLEY
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 2129
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:AR
Mailing Address - Zip Code:72018-2129
Mailing Address - Country:US
Mailing Address - Phone:501-205-4570
Mailing Address - Fax:888-305-8084
Practice Address - Street 1:4241 N GABEL DR STE 2B
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-5296
Practice Address - Country:US
Practice Address - Phone:501-205-4570
Practice Address - Fax:888-305-8084
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-31
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR291680795Medicaid