Provider Demographics
NPI:1477552313
Name:TANNER, TERRANCE NEIL (LCSW)
Entity Type:Individual
Prefix:MR
First Name:TERRANCE
Middle Name:NEIL
Last Name:TANNER
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3245 HEALTH DR STE 100
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-1380
Mailing Address - Country:US
Mailing Address - Phone:547-647-1840
Mailing Address - Fax:
Practice Address - Street 1:5314 LINCOLNWAY E
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46544-4249
Practice Address - Country:US
Practice Address - Phone:574-256-9032
Practice Address - Fax:574-256-9049
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2023-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1041C0700X1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP01672681OtherRR MEDICARE
IN300006930Medicaid
IN000000282686OtherANTHEM BCBS #
IN000000856457OtherANTHEM
IN000000856457OtherANTHEM
INP01672681OtherRR MEDICARE