Healthcare Provider Details

I. General information

NPI: 1720693187
Provider Name (Legal Business Name): GREGORY L. TANNER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/12/2020
Last Update Date: 09/12/2020
Certification Date: 09/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2121 HERNDON AVE
CLOVIS CA
93611-6302
US

IV. Provider business mailing address

2121 HERNDON AVE
CLOVIS CA
93611-6302
US

V. Phone/Fax

Practice location:
  • Phone: 562-335-6484
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number117102
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: