Provider Demographics
NPI:1396362257
Name:ANDERSON, TANNER (MS, BCBA)
Entity Type:Individual
Prefix:
First Name:TANNER
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:MS, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11417 STAMFIELD DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32821-7930
Mailing Address - Country:US
Mailing Address - Phone:727-643-4821
Mailing Address - Fax:
Practice Address - Street 1:5798 S SEMORAN BLVD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32822-4819
Practice Address - Country:US
Practice Address - Phone:888-754-0398
Practice Address - Fax:954-866-5413
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-26
Last Update Date:2022-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-125841106S00000X
1-21-53342103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician