Healthcare Provider Details

I. General information

NPI: 1265108401
Provider Name (Legal Business Name): TATUM DAYE WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TATUM DAYE TEEPLE MS, LLP

II. Dates (important events)

Enumeration Date: 08/18/2021
Last Update Date: 10/21/2025
Certification Date: 10/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

534 FOUNTAIN ST NE
GRAND RAPIDS MI
49503-3422
US

IV. Provider business mailing address

4374 VALLA CT SW
GRANDVILLE MI
49418-2452
US

V. Phone/Fax

Practice location:
  • Phone: 616-456-1178
  • Fax:
Mailing address:
  • Phone: 567-525-0050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6362009546
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: