Provider Demographics
NPI:1417582321
Name:TANNER, LORETTA E (MED)
Entity Type:Individual
Prefix:
First Name:LORETTA
Middle Name:E
Last Name:TANNER
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:LORETTA
Other - Middle Name:ELLENDER
Other - Last Name:PEREA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MED
Mailing Address - Street 1:203 SHORELINE DR
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72764-2532
Mailing Address - Country:US
Mailing Address - Phone:985-209-5327
Mailing Address - Fax:
Practice Address - Street 1:3980 W WEDINGTON DR STE 9
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72704-5791
Practice Address - Country:US
Practice Address - Phone:479-263-7602
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-11
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1511124101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional