Provider Demographics
NPI:1760523906
Name:TANNER, BRANDON J (LCSW)
Entity Type:Individual
Prefix:MR
First Name:BRANDON
Middle Name:J
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 1:215 COUNTRY LN
Mailing Address - Street 2:
Mailing Address - City:ALGONQUIN
Mailing Address - State:IL
Mailing Address - Zip Code:60102-1964
Mailing Address - Country:US
Mailing Address - Phone:847-436-4309
Mailing Address - Fax:
Practice Address - Street 1:2050 LARKIN AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-4405
Practice Address - Country:US
Practice Address - Phone:847-697-2400
Practice Address - Fax:847-697-2438
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical