Provider Demographics
NPI:1235564139
Name:TANNER, MELISSA A (PHD)
Entity Type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:A
Last Name:TANNER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6628 CHARLESWAY
Mailing Address - Street 2:
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21204-6823
Mailing Address - Country:US
Mailing Address - Phone:410-707-3403
Mailing Address - Fax:
Practice Address - Street 1:10807 FALLS RD
Practice Address - Street 2:#1419
Practice Address - City:BROOKLANDVILLE
Practice Address - State:MD
Practice Address - Zip Code:21022-7500
Practice Address - Country:US
Practice Address - Phone:410-802-1462
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-10
Last Update Date:2013-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD05109103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical