Provider Demographics
NPI:1013281815
Name:TANNENBAUM, LIBBY ROSE (PHD)
Entity type:Individual
Prefix:DR
First Name:LIBBY
Middle Name:ROSE
Last Name:TANNENBAUM
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2440 LAWRENCEVILLE HWY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-3266
Mailing Address - Country:US
Mailing Address - Phone:404-634-3400
Mailing Address - Fax:404-634-3482
Practice Address - Street 1:2440 LAWRENCEVILLE HWY
Practice Address - Street 2:SUITE 200
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-3266
Practice Address - Country:US
Practice Address - Phone:404-634-3400
Practice Address - Fax:404-634-3482
Is Sole Proprietor?:No
Enumeration Date:2012-02-27
Last Update Date:2012-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY002710103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical