Healthcare Provider Details

I. General information

NPI: 1861301590
Provider Name (Legal Business Name): TANNER HANCOCK PRUETT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2026
Last Update Date: 09/08/2026
Certification Date: 09/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

290 W 9 MILE RD
FERNDALE MI
48220-1794
US

IV. Provider business mailing address

5777 SOUTHFIELD FWY APT 1611
DETROIT MI
48228-3887
US

V. Phone/Fax

Practice location:
  • Phone: 248-398-7105
  • Fax:
Mailing address:
  • Phone: 575-373-0188
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: