Healthcare Provider Details

I. General information

NPI: 1225598063
Provider Name (Legal Business Name): RITA MARIE TATTERSALL L.C.A.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MISS RITA MARIE SURFACE

II. Dates (important events)

Enumeration Date: 03/20/2019
Last Update Date: 08/19/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1531 ROCKFORD CT
KOKOMO IN
46902-3207
US

IV. Provider business mailing address

6626 E 75TH ST STE 500
INDIANAPOLIS IN
46250-2890
US

V. Phone/Fax

Practice location:
  • Phone: 765-453-4500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number39004130A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number87001602A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: