Provider Demographics
NPI:1578921342
Name:TANNER, MELICIA IVETTE (MS)
Entity Type:Individual
Prefix:MRS
First Name:MELICIA
Middle Name:IVETTE
Last Name:TANNER
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:MELICIA
Other - Middle Name:IVETTE
Other - Last Name:BOSNJAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-8603
Mailing Address - Fax:
Practice Address - Street 1:139 LILA DOYLE DR
Practice Address - Street 2:
Practice Address - City:SENECA
Practice Address - State:SC
Practice Address - Zip Code:29672-9495
Practice Address - Country:US
Practice Address - Phone:864-482-3483
Practice Address - Fax:864-482-3497
Is Sole Proprietor?:No
Enumeration Date:2016-02-08
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC7038101YP2500X, 104100000X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC301100Medicaid
SC3333Medicare PIN