Provider Demographics
NPI:1235570771
Name:TANNER, MARTY (LISW-S)
Entity Type:Individual
Prefix:
First Name:MARTY
Middle Name:
Last Name:TANNER
Suffix:
Gender:F
Credentials:LISW-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 FAIRVEW RD
Mailing Address - Street 2:
Mailing Address - City:FREDONIA
Mailing Address - State:PA
Mailing Address - Zip Code:16124
Mailing Address - Country:US
Mailing Address - Phone:330-402-7100
Mailing Address - Fax:
Practice Address - Street 1:8166 MARKET ST STE M
Practice Address - Street 2:
Practice Address - City:BOARDMAN
Practice Address - State:OH
Practice Address - Zip Code:44512-6263
Practice Address - Country:US
Practice Address - Phone:216-831-1040
Practice Address - Fax:216-831-2667
Is Sole Proprietor?:No
Enumeration Date:2013-07-12
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.1303256-SUPV1041C0700X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor