MEDICARE: LORI TATE L.C.S.W

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	C5150	MS

General Provider Information

NPI Number	:	1477921468
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LORI TATE L.C.S.W

Provider Business Mailing Address
First Line	:	PO BOX 1268
Second Line	:
City	:	SUMMIT
State	:	MS
Zip	:	39666-1268
Country	:	US
Telephone Number	:	601-276-7665
Fax Number	:	601-276-7655

Provider Business Practice Location Address
First Line	:	804 ROBB ST
Second Line	:
City	:	SUMMIT
State	:	MS
Zip	:	39666-8291
Country	:	US
Telephone Number	:	601-276-7665
Fax Number	:	601-276-7655

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/08/2015
Last Update Date	:	09/08/2015

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