Provider Demographics
NPI:1578123832
Name:TATUM, ASTRID
Entity Type:Individual
Prefix:
First Name:ASTRID
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 1:11 S MAINE RD
Mailing Address - Street 2:
Mailing Address - City:PINEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71360-8901
Mailing Address - Country:US
Mailing Address - Phone:318-613-4663
Mailing Address - Fax:
Practice Address - Street 1:3600 JACKSON ST STE 111B
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71303-3000
Practice Address - Country:US
Practice Address - Phone:318-613-4663
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-19
Last Update Date:2019-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health