Provider Demographics
NPI:1376044131
Name:TATUM, RONALD (BA)
Entity Type:Individual
Prefix:MR
First Name:RONALD
Middle Name:
Last Name:TATUM
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17435 SW BLANTON ST
Mailing Address - Street 2:
Mailing Address - City:ALOHA
Mailing Address - State:OR
Mailing Address - Zip Code:97078-1340
Mailing Address - Country:US
Mailing Address - Phone:503-332-9112
Mailing Address - Fax:503-263-6278
Practice Address - Street 1:22018 S CENTRAL POINT RD
Practice Address - Street 2:
Practice Address - City:CANBY
Practice Address - State:OR
Practice Address - Zip Code:97013-8705
Practice Address - Country:US
Practice Address - Phone:503-221-4531
Practice Address - Fax:503-221-4531
Is Sole Proprietor?:No
Enumeration Date:2018-02-26
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500606514Medicaid