Provider Demographics
NPI:1760502280
Name:TANNER, KEVIN GLEN (LCSW)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:GLEN
Last Name:TANNER
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3105 1ST AVE STE C
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95817-1914
Mailing Address - Country:US
Mailing Address - Phone:916-549-7802
Mailing Address - Fax:916-366-1920
Practice Address - Street 1:4092 SAVANNAH LANE
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95823
Practice Address - Country:US
Practice Address - Phone:503-752-9496
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2016-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA292671041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical