MEDICARE: NIKKI REYNOLDS TATUM LCSW

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	5753	TN

General Provider Information

NPI Number	:	1861838807
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NIKKI REYNOLDS TATUM LCSW

Provider Business Mailing Address
First Line	:	221 RIVER BEND DR
Second Line	:
City	:	OCOEE
State	:	TN
Zip	:	37361-3437
Country	:	US
Telephone Number	:	423-421-0879
Fax Number	:

Provider Business Practice Location Address
First Line	:	7345 COURAGE WAY
Second Line	:
City	:	CHATTANOOGA
State	:	TN
Zip	:	37421-1555
Country	:	US
Telephone Number	:	423-605-9797
Fax Number	:	423-605-9796

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

Provider Enumeration Date	:	05/17/2013
Last Update Date	:	10/03/2013

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