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General NPI Number Information
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NPI Number | 1639458623
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Entity Type | Individual
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Provider Name | TRACY PULLIAM LCSW
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Gender | Female
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Dates
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Enumeration Date | 08/09/2011
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Last Update Date | 09/14/2016
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Provider Practice Location Address
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Address Line | 1900 E LAKE SHORE DR SUITE 201
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City | DECATUR
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State | IL
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Zip | 62521-3824
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Country | US
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Telephone | 217-422-0027
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Fax | 217-422-0041
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Provider Business Mailing Address
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Address Line | 1508 878TH ST
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City | MOUNT PULASKI
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State | IL
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Zip | 62548-6569
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Country | US
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Telephone | 217-840-6178
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Fax | 217-422-0041
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 149011563
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License Number State | IL
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