Provider Demographics
NPI:1679064596
Name:TATE, MONIQUE (PHD)
Entity Type:Individual
Prefix:
First Name:MONIQUE
Middle Name:
Last Name:TATE
Suffix:
Gender:F
Credentials:PHD
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 1841
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:GA
Mailing Address - Zip Code:30233-0036
Mailing Address - Country:US
Mailing Address - Phone:678-774-8057
Mailing Address - Fax:
Practice Address - Street 1:124 SAUNDERS ST
Practice Address - Street 2:
Practice Address - City:FLOVILLA
Practice Address - State:GA
Practice Address - Zip Code:30216-2106
Practice Address - Country:US
Practice Address - Phone:678-752-8455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-25
Last Update Date:2018-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No174400000XOther Service ProvidersSpecialist