Provider Demographics
NPI:1659820744
Name:MARCUS, TATUM (LAC)
Entity Type:Individual
Prefix:
First Name:TATUM
Middle Name:
Last Name:MARCUS
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 83261
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97283-0261
Mailing Address - Country:US
Mailing Address - Phone:503-891-9700
Mailing Address - Fax:
Practice Address - Street 1:4314 N MISSISSIPPI AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97217-3135
Practice Address - Country:US
Practice Address - Phone:503-891-9700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-29
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMFT-881106H00000X
CA144188106H00000X
ORAC177186171100000X
ORT2394106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No171100000XOther Service ProvidersAcupuncturist