Provider Demographics
NPI:1871119610
Name:TATUM, SHANNON
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:TATUM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11661 PRESTON RD STE 260
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75230-6108
Mailing Address - Country:US
Mailing Address - Phone:214-440-7313
Mailing Address - Fax:
Practice Address - Street 1:11661 PRESTON RD STE 260
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75230-6108
Practice Address - Country:US
Practice Address - Phone:214-440-7313
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-17
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician