Provider Demographics
NPI:1255677654
Name:TANNER, EBONY (LCSW)
Entity Type:Individual
Prefix:
First Name:EBONY
Middle Name:
Last Name:TANNER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13313 CRYSTAL AVE
Mailing Address - Street 2:
Mailing Address - City:GRANDVIEW
Mailing Address - State:MO
Mailing Address - Zip Code:64030-3338
Mailing Address - Country:US
Mailing Address - Phone:816-853-7273
Mailing Address - Fax:816-765-7002
Practice Address - Street 1:13313 CRYSTAL AVE
Practice Address - Street 2:
Practice Address - City:GRANDVIEW
Practice Address - State:MO
Practice Address - Zip Code:64030-3338
Practice Address - Country:US
Practice Address - Phone:816-853-7273
Practice Address - Fax:816-765-7002
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-13
Last Update Date:2013-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20110047821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical