Provider Demographics
NPI:1336654441
Name:TANCIN, ELIAS JOHN (LGSW)
Entity Type:Individual
Prefix:MR
First Name:ELIAS
Middle Name:JOHN
Last Name:TANCIN
Suffix:
Gender:M
Credentials:LGSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:185 RUFFED GROUSE RD
Mailing Address - Street 2:
Mailing Address - City:BRUCETON MILLS
Mailing Address - State:WV
Mailing Address - Zip Code:26525-6659
Mailing Address - Country:US
Mailing Address - Phone:304-282-1453
Mailing Address - Fax:301-533-3299
Practice Address - Street 1:1027 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:MD
Practice Address - Zip Code:21550-4343
Practice Address - Country:US
Practice Address - Phone:301-533-3300
Practice Address - Fax:301-533-3299
Is Sole Proprietor?:No
Enumeration Date:2017-12-12
Last Update Date:2017-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD23479104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD410467600Medicaid