Provider Demographics
NPI:1265108401
Name:WILSON, TATUM DAYE
Entity type:Individual
Prefix:
First Name:TATUM
Middle Name:DAYE
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TATUM
Other - Middle Name:DAYE
Other - Last Name:TEEPLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, LLP
Mailing Address - Street 1:4374 VALLA CT SW
Mailing Address - Street 2:
Mailing Address - City:GRANDVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49418-2452
Mailing Address - Country:US
Mailing Address - Phone:567-525-0050
Mailing Address - Fax:
Practice Address - Street 1:534 FOUNTAIN ST NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-3422
Practice Address - Country:US
Practice Address - Phone:616-456-1178
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-18
Last Update Date:2025-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6362009546103T00000X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist