=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417582321
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LORETTA E TANNER M.ED
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/11/2020
-----------------------------------------------------
Last Update Date | 03/11/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3980 W WEDINGTON DR STE 9
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72704-5791
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-263-7602
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 203 SHORELINE DR
-----------------------------------------------------
City | SPRINGDALE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72764-2532
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 985-209-5327
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 1511124
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------