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NPI Code Detail

MEDICARE: GIBRAN TATUM LPC

MEDICARE: GIBRAN TATUM LPC
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
1101YA0400XAddiction (Substance Use Disorder) Counselor080696OH
2101YP2500XProfessional CounselorC1801524OH

General Provider Information

NPI Number : 1982008074
Entity Type Code : Individual
Provider Name (Legal Business Name) : GIBRAN TATUM LPC
Provider Business Mailing Address
First Line : 1590 CRESTVIEW DR
Second Line :
City : ASHLAND
State : OH
Zip : 44805-3560
Country : US
Telephone Number : 419-289-0970
Fax Number :
Provider Business Practice Location Address
First Line : 1590 CRESTVIEW DR
Second Line :
City : ASHLAND
State : OH
Zip : 44805-3560
Country : US
Telephone Number : 419-289-0970
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/17/2014
Last Update Date : 04/21/2020

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