Healthcare Provider Details

I. General information

NPI: 1306604863
Provider Name (Legal Business Name): AMANDA ELIZABETH TANNER LPCC, NCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/11/2024
Last Update Date: 01/02/2026
Certification Date: 01/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 PARK AVE
GALLUP NM
87301-5806
US

IV. Provider business mailing address

PO BOX 4837
GALLUP NM
87305-4837
US

V. Phone/Fax

Practice location:
  • Phone: 505-879-9938
  • Fax:
Mailing address:
  • Phone: 505-879-9938
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberCTB-2025-0696
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: