Provider Demographics
NPI:1003175167
Name:TANNER, MARTIN PATTERSON (LCSW)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:PATTERSON
Last Name:TANNER
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:809 S 6TH ST
Mailing Address - Street 2:
Mailing Address - City:BASIN
Mailing Address - State:WY
Mailing Address - Zip Code:82410-9510
Mailing Address - Country:US
Mailing Address - Phone:661-463-0501
Mailing Address - Fax:
Practice Address - Street 1:44648 15TH ST W
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-2806
Practice Address - Country:US
Practice Address - Phone:661-463-0501
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-10
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYLCSW16391041C0700X
CALCSW225091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical