Healthcare Provider Details

I. General information

NPI: 1801686167
Provider Name (Legal Business Name): TATUM D. TEEPLE, MS, TLLP, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2025
Last Update Date: 05/28/2025
Certification Date: 05/28/2025
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: 567-525-0059
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name: TATUM DAYE TEEPLE
Title or Position: SOLE MEMBER
Credential: MS, MLP
Phone: 567-525-0050