Provider Demographics
NPI:1407989940
Name:TANNER, CHAD DOUGLAS (BSWAM LMT,CMT)
Entity Type:Individual
Prefix:
First Name:CHAD
Middle Name:DOUGLAS
Last Name:TANNER
Suffix:
Gender:M
Credentials:BSWAM LMT,CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 91
Mailing Address - Street 2:
Mailing Address - City:HARDWICK
Mailing Address - State:VT
Mailing Address - Zip Code:05843-0091
Mailing Address - Country:US
Mailing Address - Phone:802-279-3839
Mailing Address - Fax:
Practice Address - Street 1:4 S MAIN ST
Practice Address - Street 2:HARDWICK INN 3RD FLOOR SUITE 10
Practice Address - City:HARDWICK
Practice Address - State:VT
Practice Address - Zip Code:05843
Practice Address - Country:US
Practice Address - Phone:802-279-3839
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMAT-9525225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist