Provider Demographics
NPI:1679229959
Name:TANNER, LAURA (LCSW)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:TANNER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2078
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:TX
Mailing Address - Zip Code:76234-6156
Mailing Address - Country:US
Mailing Address - Phone:940-626-2300
Mailing Address - Fax:940-626-2315
Practice Address - Street 1:2010 BEN MERRITT DR UNIT A
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:TX
Practice Address - Zip Code:76234-3853
Practice Address - Country:US
Practice Address - Phone:940-626-2300
Practice Address - Fax:940-626-2543
Is Sole Proprietor?:No
Enumeration Date:2022-02-25
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX566001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1679229959Medicaid
TX8RG827OtherBCBS