Provider Demographics
NPI:1417172172
Name:TANNER, ELLEN MARIE (OTRL)
Entity Type:Individual
Prefix:MRS
First Name:ELLEN
Middle Name:MARIE
Last Name:TANNER
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:MS
Other - First Name:ELLEN
Other - Middle Name:MARIE
Other - Last Name:TANNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTRL
Mailing Address - Street 1:4823 STOREYLAND DR
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-5835
Mailing Address - Country:US
Mailing Address - Phone:312-593-4871
Mailing Address - Fax:
Practice Address - Street 1:4823 STOREYLAND DR
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-5835
Practice Address - Country:US
Practice Address - Phone:312-593-4871
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2014-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.007674225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist