Provider Demographics
NPI:1497879860
Name:TANNER, BARRY A (PHD)
Entity Type:Individual
Prefix:
First Name:BARRY
Middle Name:A
Last Name:TANNER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4201 SAINT ANTOINE ST
Mailing Address - Street 2:LIFE STRESS CENTER 3S-14
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-2153
Mailing Address - Country:US
Mailing Address - Phone:313-745-4811
Mailing Address - Fax:313-966-7196
Practice Address - Street 1:4201 SAINT ANTOINE ST
Practice Address - Street 2:LIFE STRESS CENTER 3S-14
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2153
Practice Address - Country:US
Practice Address - Phone:313-745-4811
Practice Address - Fax:313-966-7196
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301002031103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
11290248OtherCAQH PID
MISO6166Medicare UPIN