Healthcare Provider Details

I. General information

NPI: 1033113857
Provider Name (Legal Business Name): CHRISTIE LYNN TANNER-GORMAN PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/09/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

170 THOMAS JOHNSON DR STE 200
FREDERICK MD
21702-6200
US

IV. Provider business mailing address

170 THOMAS JOHNSON DR STE 200
FREDERICK MD
21702-6200
US

V. Phone/Fax

Practice location:
  • Phone: 301-695-8390
  • Fax: 301-694-7906
Mailing address:
  • Phone: 301-695-8390
  • Fax: 301-694-7906

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number04158
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: