Provider Demographics
NPI:1487451746
Name:TATUM, NATHANIEL MYRON (SUDRC)
Entity type:Individual
Prefix:MR
First Name:NATHANIEL
Middle Name:MYRON
Last Name:TATUM
Suffix:
Gender:M
Credentials:SUDRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3320 VISTA AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:LEMON GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:91945-2239
Mailing Address - Country:US
Mailing Address - Phone:619-952-2944
Mailing Address - Fax:
Practice Address - Street 1:2516 A ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92102-2111
Practice Address - Country:US
Practice Address - Phone:619-952-2944
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-25
Last Update Date:2025-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty