Healthcare Provider Details

I. General information

NPI: 1821670100
Provider Name (Legal Business Name): DENISE EVADNE TATUM LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/26/2021
Last Update Date: 04/26/2021
Certification Date: 04/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10138 HULL STREET RD
MIDLOTHIAN VA
23112-3357
US

IV. Provider business mailing address

3900 W BROAD ST
RICHMOND VA
23230-3914
US

V. Phone/Fax

Practice location:
  • Phone: 804-744-1114
  • Fax: 804-893-1114
Mailing address:
  • Phone: 804-353-4461
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904012754
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: