Provider Demographics
NPI:1225598063
Name:TATTERSALL, RITA MARIE (LCAC)
Entity Type:Individual
Prefix:MRS
First Name:RITA
Middle Name:MARIE
Last Name:TATTERSALL
Suffix:
Gender:F
Credentials:LCAC
Other - Prefix:MISS
Other - First Name:RITA
Other - Middle Name:MARIE
Other - Last Name:SURFACE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6626 E 75TH ST STE 500
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2890
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2765 ALBRIGHT RD STE A
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46902-3996
Practice Address - Country:US
Practice Address - Phone:765-450-9214
Practice Address - Fax:765-792-4234
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-20
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN87001602A101Y00000X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor