MEDICARE: COURTNEY TATUM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor	84740	TX

General Provider Information

NPI Number	:	1710633011
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	COURTNEY TATUM

Provider Business Mailing Address
First Line	:	1021 STONE CHAPEL WAY
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76179-7307
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1021 STONE CHAPEL WAY
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76179-7307
Country	:	US
Telephone Number	:	682-238-1016
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/24/2022
Last Update Date	:	02/24/2022

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Directions to “ COURTNEY TATUM ” Practice Location

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