Provider Demographics
NPI:1871187500
Name:TATUM, ANGEL NICOLE (LSW)
Entity Type:Individual
Prefix:
First Name:ANGEL
Middle Name:NICOLE
Last Name:TATUM
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8141 S MARSHFIELD AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60620-5791
Mailing Address - Country:US
Mailing Address - Phone:912-580-9885
Mailing Address - Fax:
Practice Address - Street 1:500 N MICHIGAN AVE STE 1530
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-3758
Practice Address - Country:US
Practice Address - Phone:630-428-7890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-23
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 101YP1600X, 101Y00000X
IL150.104413104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No101Y00000XBehavioral Health & Social Service ProvidersCounselor