Provider Demographics
NPI:1013055573
Name:TANNER, NANCY KATHLEEN (LCSW)
Entity Type:Individual
Prefix:MS
First Name:NANCY
Middle Name:KATHLEEN
Last Name:TANNER
Suffix:
Gender:F
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:PO BOX 460283
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33346-0283
Mailing Address - Country:US
Mailing Address - Phone:954-868-6136
Mailing Address - Fax:954-761-1412
Practice Address - Street 1:105 NE 4TH ST
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33301-3239
Practice Address - Country:US
Practice Address - Phone:954-868-6136
Practice Address - Fax:954-761-1412
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-04
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW00022841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL768498300Medicaid