Provider Demographics
NPI:1447837737
Name:TATUM, SAMANTHA R (LCSW)
Entity type:Individual
Prefix:MS
First Name:SAMANTHA
Middle Name:R
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 1:1189 TRINITY AVE
Mailing Address - Street 2:
Mailing Address - City:SEASIDE
Mailing Address - State:CA
Mailing Address - Zip Code:93955-5322
Mailing Address - Country:US
Mailing Address - Phone:831-224-0645
Mailing Address - Fax:
Practice Address - Street 1:419 WEBSTER ST STE 202
Practice Address - Street 2:
Practice Address - City:MONTEREY
Practice Address - State:CA
Practice Address - Zip Code:93940-3241
Practice Address - Country:US
Practice Address - Phone:408-600-0089
Practice Address - Fax:510-756-0812
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-24
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCSW99259101YM0800X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health