Provider Demographics
NPI:1518557081
Name:WETZEL, TANNER (BEHAVIORAL TECHNICIA)
Entity Type:Individual
Prefix:
First Name:TANNER
Middle Name:
Last Name:WETZEL
Suffix:
Gender:M
Credentials:BEHAVIORAL TECHNICIA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11037 WARNER AVE # 339
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-4007
Mailing Address - Country:US
Mailing Address - Phone:800-273-4292
Mailing Address - Fax:714-596-6274
Practice Address - Street 1:3535 N LOMBARD ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97217-5901
Practice Address - Country:US
Practice Address - Phone:800-273-4292
Practice Address - Fax:714-596-6274
Is Sole Proprietor?:No
Enumeration Date:2021-01-19
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician