Provider Demographics
NPI:1063531663
Name:TATE, VIVIAN KELLER (LCSW)
Entity type:Individual
Prefix:
First Name:VIVIAN
Middle Name:KELLER
Last Name:TATE
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:P.O. BOX 7827
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39506
Mailing Address - Country:US
Mailing Address - Phone:228-897-7730
Mailing Address - Fax:228-575-0886
Practice Address - Street 1:1403 43RD AVENUE
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501
Practice Address - Country:US
Practice Address - Phone:228-897-7730
Practice Address - Fax:228-575-0886
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2010-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS25611041C0700X
MSC20581041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS800000055Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER