Provider Demographics
NPI:1124380951
Name:TATUM, AUDREY ANDREA (MSED)
Entity Type:Individual
Prefix:MS
First Name:AUDREY
Middle Name:ANDREA
Last Name:TATUM
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:92 HUSSON ST
Mailing Address - Street 2:APT D
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10305-1124
Mailing Address - Country:US
Mailing Address - Phone:718-282-9117
Mailing Address - Fax:
Practice Address - Street 1:8785 SW 165TH AVE STE 103
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33193-5827
Practice Address - Country:US
Practice Address - Phone:786-206-6500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-07
Last Update Date:2020-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No174400000XOther Service ProvidersSpecialist