Healthcare Provider Details

I. General information

NPI: 1932960010
Provider Name (Legal Business Name): TATUM RICHARDSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2024
Last Update Date: 06/04/2026
Certification Date: 06/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4140 E EDGEMONT AVE
PHOENIX AZ
85008-1411
US

IV. Provider business mailing address

4340 E INDIAN SCHOOL RD STE 21-297
PHOENIX AZ
85018-5394
US

V. Phone/Fax

Practice location:
  • Phone: 602-898-4053
  • Fax:
Mailing address:
  • Phone: 602-898-4053
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberTSLP17368
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: