Provider Demographics
NPI:1497928899
Name:TANNER, MARY BETH
Entity Type:Individual
Prefix:
First Name:MARY BETH
Middle Name:
Last Name:TANNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HC 89 BOX 119
Mailing Address - Street 2:
Mailing Address - City:MT ZION
Mailing Address - State:WV
Mailing Address - Zip Code:26151-9734
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:HC 89 BOX 119
Practice Address - Street 2:
Practice Address - City:MOUNT ZION
Practice Address - State:WV
Practice Address - Zip Code:26151-9734
Practice Address - Country:US
Practice Address - Phone:304-354-7011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-07
Last Update Date:2008-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV9400182000Medicaid