Healthcare Provider Details

I. General information

NPI: 1194001040
Provider Name (Legal Business Name): FAITH DOLORES TATUM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/24/2011
Last Update Date: 04/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2434 S EASON BLVD
TUPELO MS
38804-6942
US

IV. Provider business mailing address

56 VILLAGE LOOP
STARKVILLE MS
39759-1635
US

V. Phone/Fax

Practice location:
  • Phone: 662-640-4595
  • Fax:
Mailing address:
  • Phone: 662-769-6800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: