Provider Demographics
NPI:1861838807
Name:TATUM, NIKKI REYNOLDS (LCSW)
Entity Type:Individual
Prefix:
First Name:NIKKI
Middle Name:REYNOLDS
Last Name:TATUM
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 RIVER BEND DR
Mailing Address - Street 2:
Mailing Address - City:OCOEE
Mailing Address - State:TN
Mailing Address - Zip Code:37361-3437
Mailing Address - Country:US
Mailing Address - Phone:423-421-0879
Mailing Address - Fax:
Practice Address - Street 1:7345 COURAGE WAY
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-1555
Practice Address - Country:US
Practice Address - Phone:423-605-9797
Practice Address - Fax:423-605-9796
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-17
Last Update Date:2013-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN57531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical