Provider Demographics
NPI:1932575289
Name:JOHNSTON TATUM, MAEGAN LEIGH (PHD, LPC-S, NCC)
Entity Type:Individual
Prefix:DR
First Name:MAEGAN
Middle Name:LEIGH
Last Name:JOHNSTON TATUM
Suffix:
Gender:F
Credentials:PHD, LPC-S, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 COUNTY ROAD 325
Mailing Address - Street 2:
Mailing Address - City:TAYLOR
Mailing Address - State:MS
Mailing Address - Zip Code:38673-4535
Mailing Address - Country:US
Mailing Address - Phone:662-801-0011
Mailing Address - Fax:
Practice Address - Street 1:507 HERITAGE DR STE 102
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655-5571
Practice Address - Country:US
Practice Address - Phone:662-506-2059
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-20
Last Update Date:2022-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2152101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional