Basic Information
| Provider Information | |||||||||
| NPI: | 1508365693 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TATKENHORST | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | FRANCES | ||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1800 COMMUNITY | ||||||||
| Address2: | |||||||||
| City: | CLINTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 647358804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6608908183 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1200 MARTIN ST UNIT 2 | ||||||||
| Address2: | |||||||||
| City: | CUBA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 65453 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8884031071 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/05/2018 | ||||||||
| LastUpdateDate: | 05/14/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 2005030149 | MO | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.