Provider Demographics
NPI:1730673351
Name:TANNER, AMANDA LOUISE (LSW)
Entity Type:Individual
Prefix:MS
First Name:AMANDA
Middle Name:LOUISE
Last Name:TANNER
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 CROSS STREET
Mailing Address - Street 2:COMMUNITY SUPPORT SERVICES, INC
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44311-1026
Mailing Address - Country:US
Mailing Address - Phone:330-996-9141
Mailing Address - Fax:330-253-0377
Practice Address - Street 1:150 CROSS STREET
Practice Address - Street 2:COMMUNITY SUPPORT SERVICES, INC
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44311-1026
Practice Address - Country:US
Practice Address - Phone:330-996-9141
Practice Address - Fax:330-253-0377
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-18
Last Update Date:2021-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.1601288104100000X
OHI.20021971041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0317175Medicaid