Provider Demographics
NPI:1861968455
Name:SUMNER, TATUM
Entity type:Individual
Prefix:
First Name:TATUM
Middle Name:
Last Name:SUMNER
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 1:4020 CAPENSIS LN
Mailing Address - Street 2:
Mailing Address - City:RAVENEL
Mailing Address - State:SC
Mailing Address - Zip Code:29470-3335
Mailing Address - Country:US
Mailing Address - Phone:803-664-1243
Mailing Address - Fax:
Practice Address - Street 1:887 JOHNNIE DODDS BLVD
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-3154
Practice Address - Country:US
Practice Address - Phone:803-664-1243
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-22
Last Update Date:2024-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
SC149381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician