Provider Demographics
NPI:1962018747
Name:TANKERSLEY, HUBERT PIERCE III
Entity Type:Individual
Prefix:
First Name:HUBERT
Middle Name:PIERCE
Last Name:TANKERSLEY
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1815 OLD 41 HWY NW STE 110
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30152-4422
Mailing Address - Country:US
Mailing Address - Phone:678-468-9103
Mailing Address - Fax:
Practice Address - Street 1:1815 OLD 41 HWY NW STE 110
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30152-4422
Practice Address - Country:US
Practice Address - Phone:678-468-9103
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-17
Last Update Date:2020-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPENDING101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional