Basic Information
| Provider Information | |||||||||
| NPI: | 1578828109 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COLEMAN | ||||||||
| FirstName: | TRACY | ||||||||
| MiddleName: | LAUREL | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LPC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FITCH | ||||||||
| OtherFirstName: | TRACY | ||||||||
| OtherMiddleName: | LAUREL | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LPC | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1815 PLEASANT GROVE ROAD | ||||||||
| Address2: | |||||||||
| City: | JONESBORO | ||||||||
| State: | AR | ||||||||
| PostalCode: | 724057870 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6709336886 | ||||||||
| FaxNumber: | 8709339395 | ||||||||
| Practice Location | |||||||||
| Address1: | 2126 N 1ST STREET | ||||||||
| Address2: | SUITE F | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 720762868 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5019825000 | ||||||||
| FaxNumber: | 5019825007 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2012 | ||||||||
| LastUpdateDate: | 10/13/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | P1702246 | AR | Y | Behavioral Health & Social Service Providers | Counselor | Professional | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.