Provider Demographics
NPI:1912068800
Name:TATUM, SUSAN CONNOR (LCSW)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:CONNOR
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 1:4855 28TH ST S
Mailing Address - Street 2:B2
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22206-1375
Mailing Address - Country:US
Mailing Address - Phone:703-838-4455
Mailing Address - Fax:703-838-5070
Practice Address - Street 1:720 N SAINT ASAPH ST
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22314-1912
Practice Address - Country:US
Practice Address - Phone:703-838-4455
Practice Address - Fax:703-838-5070
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040030751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA188523OtherANTHEM
VA0057OtherCAREFIRST BCBS
VA298443OtherAMERIGROUP VIRGINIA INC
VA546001103002OtherTRICARE
VA0057OtherCAREFIRST BCBS