Healthcare Provider Details

I. General information

NPI: 1114389871
Provider Name (Legal Business Name): MARY K TATUM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2016
Last Update Date: 03/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 N FLAGLER DR SUITE P-300
WEST PALM BEACH FL
33401-4321
US

IV. Provider business mailing address

515 N FLAGLER DR SUITE P-300
WEST PALM BEACH FL
33401-4321
US

V. Phone/Fax

Practice location:
  • Phone: 561-908-4858
  • Fax: 561-828-0589
Mailing address:
  • Phone: 561-908-4858
  • Fax: 561-828-0589

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code102L00000X
TaxonomyPsychoanalyst
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: MARY KATHERINE TATUM
Title or Position: OWNER
Credential: LMHC
Phone: 561-908-4858