Provider Demographics
NPI:1407836661
Name:TANNER, VICKI LYNN (PHD)
Entity Type:Individual
Prefix:DR
First Name:VICKI
Middle Name:LYNN
Last Name:TANNER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2024 ARKANSAS VALLEY DR
Mailing Address - Street 2:SUITE 308
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72212-4166
Mailing Address - Country:US
Mailing Address - Phone:501-223-9878
Mailing Address - Fax:501-868-7475
Practice Address - Street 1:2024 ARKANSAS VALLEY DR
Practice Address - Street 2:SUITE 308
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72212-4166
Practice Address - Country:US
Practice Address - Phone:501-223-9878
Practice Address - Fax:501-868-7475
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR78-26P103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR56448Medicare ID - Type Unspecified