Provider Demographics
NPI:1194001040
Name:TATUM, FAITH DOLORES
Entity Type:Individual
Prefix:
First Name:FAITH
Middle Name:DOLORES
Last Name:TATUM
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 1:56 VILLAGE LOOP
Mailing Address - Street 2:
Mailing Address - City:STARKVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39759-1635
Mailing Address - Country:US
Mailing Address - Phone:662-769-6800
Mailing Address - Fax:
Practice Address - Street 1:2434 S EASON BLVD
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38804-6942
Practice Address - Country:US
Practice Address - Phone:662-640-4595
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-24
Last Update Date:2016-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health