Healthcare Provider Details

I. General information

NPI: 1477552313
Provider Name (Legal Business Name): TERRANCE NEIL TANNER LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2005
Last Update Date: 03/17/2023
Certification Date: 03/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5314 LINCOLNWAY E
MISHAWAKA IN
46544-4249
US

IV. Provider business mailing address

3245 HEALTH DR STE 100
GRANGER IN
46530-1380
US

V. Phone/Fax

Practice location:
  • Phone: 574-256-9032
  • Fax: 574-256-9049
Mailing address:
  • Phone: 547-647-1840
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1041C0700X
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: