Provider Demographics
NPI:1285188284
Name:TATUM, ALYSSA
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:
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 1:1826 FAIRFAX AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45207-1812
Mailing Address - Country:US
Mailing Address - Phone:937-760-0289
Mailing Address - Fax:
Practice Address - Street 1:1826 FAIRFAX AVE APT 1
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45207
Practice Address - Country:US
Practice Address - Phone:937-760-0289
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-08
Last Update Date:2018-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP.12610235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist