Provider Demographics
NPI:1649417585
Name:TANNER, AMY ELIZABETH (MA)
Entity Type:Individual
Prefix:MS
First Name:AMY
Middle Name:ELIZABETH
Last Name:TANNER
Suffix:
Gender:F
Credentials:MA
Other - Prefix:MS
Other - First Name:AMY
Other - Middle Name:ELIZABETH
Other - Last Name:ELVINGTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1215 NW 25TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73106-5629
Mailing Address - Country:US
Mailing Address - Phone:405-525-2525
Mailing Address - Fax:405-524-3549
Practice Address - Street 1:1215 NW 25TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73106-5629
Practice Address - Country:US
Practice Address - Phone:405-525-2525
Practice Address - Fax:405-524-3549
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-14
Last Update Date:2017-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4454101YM0800X
171W00000X, 106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171W00000XOther Service ProvidersContractor