Provider Demographics
NPI:1689269003
Name:TANNER, ERIC JON (LCPC)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:JON
Last Name:TANNER
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3716 MARIEME DR
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-1933
Mailing Address - Country:US
Mailing Address - Phone:630-390-4110
Mailing Address - Fax:
Practice Address - Street 1:3716 MARIEME DR
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-1933
Practice Address - Country:US
Practice Address - Phone:630-390-4110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-08
Last Update Date:2022-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.13458101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional