Provider Demographics
NPI:1467108332
Name:LILLIBRIDGE, TATUM
Entity Type:Individual
Prefix:
First Name:TATUM
Middle Name:
Last Name:LILLIBRIDGE
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 1:2858 MONROE DR
Mailing Address - Street 2:
Mailing Address - City:AMES
Mailing Address - State:IA
Mailing Address - Zip Code:50010-4364
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1315 S BELL AVE STE 108
Practice Address - Street 2:
Practice Address - City:AMES
Practice Address - State:IA
Practice Address - Zip Code:50010-7730
Practice Address - Country:US
Practice Address - Phone:515-290-1134
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-01
Last Update Date:2022-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician