Provider Demographics
NPI:1043467780
Name:TATE, AUNDREA CHABLIS
Entity Type:Individual
Prefix:MISS
First Name:AUNDREA
Middle Name:CHABLIS
Last Name:TATE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 768
Mailing Address - Street 2:
Mailing Address - City:MCCOMB
Mailing Address - State:MS
Mailing Address - Zip Code:39649-0768
Mailing Address - Country:US
Mailing Address - Phone:601-249-4219
Mailing Address - Fax:601-249-4234
Practice Address - Street 1:1701 WHITE ST
Practice Address - Street 2:
Practice Address - City:MCCOMB
Practice Address - State:MS
Practice Address - Zip Code:39648-2711
Practice Address - Country:US
Practice Address - Phone:601-249-4219
Practice Address - Fax:601-249-4234
Is Sole Proprietor?:No
Enumeration Date:2008-08-25
Last Update Date:2008-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225586101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor