Provider Demographics
NPI:1871000117
Name:BRANDI TANNER, PH.D., LLC
Entity Type:Organization
Organization Name:BRANDI TANNER, PH.D., LLC
Other - Org Name:LIGHTWAY PSYCHOLOGICAL SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRANDI
Authorized Official - Middle Name:
Authorized Official - Last Name:TANNER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:404-491-1684
Mailing Address - Street 1:2801 BUFORD HWY NE STE 503
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:GA
Mailing Address - Zip Code:30329-2137
Mailing Address - Country:US
Mailing Address - Phone:404-491-1684
Mailing Address - Fax:844-646-0336
Practice Address - Street 1:2801 BUFORD HWY NE STE 503
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:GA
Practice Address - Zip Code:30329-2137
Practice Address - Country:US
Practice Address - Phone:404-491-1684
Practice Address - Fax:844-646-0336
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-09
Last Update Date:2018-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchoolGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003151503CMedicaid