=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124120712
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TRACY L BAXLEY TULLOS LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/02/2006
-----------------------------------------------------
Last Update Date | 05/05/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3106 W 2ND CT SUITE 1
-----------------------------------------------------
City | RUSSELLVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72801-4503
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-880-5100
-----------------------------------------------------
Fax | 479-880-5297
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3106 W 2ND CT SUITE 1
-----------------------------------------------------
City | RUSSELLVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72801-4503
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-880-5100
-----------------------------------------------------
Fax | 479-880-5297
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 2041C
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------