Provider Demographics
NPI:1477184935
Name:TATUM, ASHLEY (MSW, LMSW)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:
Last Name:TATUM
Suffix:
Gender:F
Credentials:MSW, LMSW
Other - Prefix:
Other - First Name:ASHLEY
Other - Middle Name:
Other - Last Name:DERRICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2153 E JOYCE BLVD STE 201
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-5285
Mailing Address - Country:US
Mailing Address - Phone:479-575-9471
Mailing Address - Fax:479-587-9392
Practice Address - Street 1:114 E CRANDALL AVE STE B
Practice Address - Street 2:
Practice Address - City:HARRISON
Practice Address - State:AR
Practice Address - Zip Code:72601-3628
Practice Address - Country:US
Practice Address - Phone:870-741-8484
Practice Address - Fax:870-741-4088
Is Sole Proprietor?:No
Enumeration Date:2020-02-03
Last Update Date:2020-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR0000171M00000X
AR9963-M1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
14616315OtherCAQH