Provider Demographics
NPI:1629593173
Name:TATUM, DOMONICQUE (EDD, LCSW)
Entity Type:Individual
Prefix:DR
First Name:DOMONICQUE
Middle Name:
Last Name:TATUM
Suffix:
Gender:M
Credentials:EDD, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16300 KEDZIE AVE
Mailing Address - Street 2:
Mailing Address - City:MARKHAM
Mailing Address - State:IL
Mailing Address - Zip Code:60428-5508
Mailing Address - Country:US
Mailing Address - Phone:571-282-5193
Mailing Address - Fax:
Practice Address - Street 1:16300 KEDZIE AVE
Practice Address - Street 2:
Practice Address - City:MARKHAM
Practice Address - State:IL
Practice Address - Zip Code:60428-5508
Practice Address - Country:US
Practice Address - Phone:571-282-5193
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0174481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical