Healthcare Provider Details

I. General information

NPI: 1851317895
Provider Name (Legal Business Name): CHARLES H TATUM PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 09/03/2025
Certification Date: 09/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12050 VANCE JACKSON RD. BLDG. 2 SUITE 201
SAN ANTONIO TX
78230-1183
US

IV. Provider business mailing address

12050 VANCE JACKSON RD BLDG 2 STE 201
SAN ANTONIO TX
78230-1183
US

V. Phone/Fax

Practice location:
  • Phone: 210-699-8881
  • Fax: 210-699-0503
Mailing address:
  • Phone: 210-699-8881
  • Fax: 210-699-0503

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number1884
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number10968
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number8835
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: