Provider Demographics
NPI:1407343932
Name:TANNER, MICHELLE LYNN (LPC)
Entity Type:Individual
Prefix:MISS
First Name:MICHELLE
Middle Name:LYNN
Last Name:TANNER
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1107 NANTICOKE ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21230-1918
Mailing Address - Country:US
Mailing Address - Phone:804-389-7916
Mailing Address - Fax:
Practice Address - Street 1:2 MANHATTANVILLE RD
Practice Address - Street 2:
Practice Address - City:PURCHASE
Practice Address - State:NY
Practice Address - Zip Code:10577-2113
Practice Address - Country:US
Practice Address - Phone:800-835-2362
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-19
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701007600101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor