Provider Demographics
NPI:1629288899
Name:TANNER, ANDREA LASHAWN (ABD, LPC, LMFT, LADC)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:LASHAWN
Last Name:TANNER
Suffix:
Gender:F
Credentials:ABD, LPC, LMFT, LADC
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:LASHAWN
Other - Last Name:TANNER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:ABD, LPC, LMFT, LADC
Mailing Address - Street 1:PO BOX 40
Mailing Address - Street 2:
Mailing Address - City:FULSHEAR
Mailing Address - State:TX
Mailing Address - Zip Code:77441-0040
Mailing Address - Country:US
Mailing Address - Phone:580-512-9862
Mailing Address - Fax:
Practice Address - Street 1:10 SW 2ND ST STE 4
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73501-4027
Practice Address - Country:US
Practice Address - Phone:580-512-9862
Practice Address - Fax:580-585-5890
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK354101YA0400X
LA705106H00000X
OK3171101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist