Provider Demographics
NPI:1851317895
Name:TATUM, CHARLES H (PHD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:H
Last Name:TATUM
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12050 VANCE JACKSON RD
Mailing Address - Street 2:BLDG 2 STE 201
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78230-1183
Mailing Address - Country:US
Mailing Address - Phone:210-699-8881
Mailing Address - Fax:210-699-0503
Practice Address - Street 1:12050 VANCE JACKSON RD.
Practice Address - Street 2:BLDG. 2 SUITE 201
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78230-1183
Practice Address - Country:US
Practice Address - Phone:210-699-8881
Practice Address - Fax:210-699-0503
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10968103TB0200X
TX1884106H00000X
TX8835101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX027365801Medicaid