Healthcare Provider Details

I. General information

NPI: 1942017454
Provider Name (Legal Business Name): SANDRA L. TATUM LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/17/2024
Last Update Date: 12/17/2024
Certification Date: 12/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4305 SNOWDEN CT NE
RIO RANCHO NM
87124-4831
US

IV. Provider business mailing address

4305 SNOWDEN CT NE
RIO RANCHO NM
87124-4831
US

V. Phone/Fax

Practice location:
  • Phone: 505-507-0960
  • Fax:
Mailing address:
  • Phone: 505-507-0960
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCTB-2024-0490
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: