Provider Demographics
NPI:1366901712
Name:TATUM, KATHLEEN DEAL (LCSW)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:DEAL
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 1:296 TURPENTINE CIR
Mailing Address - Street 2:
Mailing Address - City:JESUP
Mailing Address - State:GA
Mailing Address - Zip Code:31545-2574
Mailing Address - Country:US
Mailing Address - Phone:912-424-6134
Mailing Address - Fax:
Practice Address - Street 1:296 TURPENTINE CIR
Practice Address - Street 2:
Practice Address - City:JESUP
Practice Address - State:GA
Practice Address - Zip Code:31545-2574
Practice Address - Country:US
Practice Address - Phone:912-424-6134
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-15
Last Update Date:2024-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0081651041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GACSW008165OtherSTATE LICENSE