Healthcare Provider Details

I. General information

NPI: 1497863138
Provider Name (Legal Business Name): HAERYUN KIM TATUM LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

913 NW GARDEN VALLEY BLVD
ROSEBURG OR
97470-6523
US

IV. Provider business mailing address

362 N RIVER DR
ROSEBURG OR
97470-8008
US

V. Phone/Fax

Practice location:
  • Phone: 541-440-1000
  • Fax:
Mailing address:
  • Phone: 541-229-3001
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberL003600
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: