Provider Demographics
NPI:1366672313
Name:TATUM, MATTHEW THOMAS (PSYD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:THOMAS
Last Name:TATUM
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7065 N MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-8013
Mailing Address - Country:US
Mailing Address - Phone:559-326-7775
Mailing Address - Fax:
Practice Address - Street 1:2343 DEAUVILLE CIR
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93619-4292
Practice Address - Country:US
Practice Address - Phone:559-797-4460
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-23
Last Update Date:2020-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY25350103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical