Provider Demographics
NPI:1942794920
Name:TANNER, NICHOLAS ANDREW (PHD)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:ANDREW
Last Name:TANNER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3141 N 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013-4360
Mailing Address - Country:US
Mailing Address - Phone:928-607-4846
Mailing Address - Fax:
Practice Address - Street 1:3141 N 3RD AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013
Practice Address - Country:US
Practice Address - Phone:602-914-1520
Practice Address - Fax:602-470-5064
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-21
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZPSY-004974103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist