Provider Demographics
NPI:1790993905
Name:HARRIS, TANNA LOU (MED,CCC,SLP)
Entity Type:Individual
Prefix:MS
First Name:TANNA
Middle Name:LOU
Last Name:HARRIS
Suffix:
Gender:F
Credentials:MED,CCC,SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 DOUGLAS AVE
Mailing Address - Street 2:SUITE 1030
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32714-2593
Mailing Address - Country:US
Mailing Address - Phone:407-617-1323
Mailing Address - Fax:407-788-1030
Practice Address - Street 1:650 DOUGLAS AVE
Practice Address - Street 2:SUITE 1030
Practice Address - City:ALTAMONTE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32714-2593
Practice Address - Country:US
Practice Address - Phone:407-617-1323
Practice Address - Fax:407-788-1030
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA4318235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL887044600Medicaid
FLS2323OtherSPEECH PATHOLOGIST