Provider Demographics
NPI:1447610225
Name:TANNENBAUM, LORI (PHD)
Entity Type:Individual
Prefix:DR
First Name:LORI
Middle Name:
Last Name:TANNENBAUM
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 1:147 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:SUMMIT
Mailing Address - State:NJ
Mailing Address - Zip Code:07901-5915
Mailing Address - Country:US
Mailing Address - Phone:908-273-1324
Mailing Address - Fax:
Practice Address - Street 1:147 BROAD ST
Practice Address - Street 2:
Practice Address - City:SUMMIT
Practice Address - State:NJ
Practice Address - Zip Code:07901-5915
Practice Address - Country:US
Practice Address - Phone:908-273-1324
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-07
Last Update Date:2016-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017780103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical