Healthcare Provider Details

I. General information

NPI: 1760523906
Provider Name (Legal Business Name): BRANDON J TANNER LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2050 LARKIN AVE SUITE 202
ELGIN IL
60123-4405
US

IV. Provider business mailing address

215 COUNTRY LN
ALGONQUIN IL
60102-1964
US

V. Phone/Fax

Practice location:
  • Phone: 847-697-2400
  • Fax: 847-697-2438
Mailing address:
  • Phone: 847-436-4309
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: