Healthcare Provider Details

I. General information

NPI: 1457980476
Provider Name (Legal Business Name): SHAWNA M TANNER PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2020
Last Update Date: 03/04/2026
Certification Date: 03/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 68TH ST SE
GRAND RAPIDS MI
49548-6927
US

IV. Provider business mailing address

300 68TH ST SE
GRAND RAPIDS MI
49548-6927
US

V. Phone/Fax

Practice location:
  • Phone: 616-327-8133
  • Fax: 616-327-6904
Mailing address:
  • Phone: 616-455-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY50000290
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6301019355
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: