Provider Demographics
NPI:1134755374
Name:TANNER, SCOTT ALAN (PHD)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:ALAN
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 1:1207 UTICA ST
Mailing Address - Street 2:
Mailing Address - City:ORISKANY
Mailing Address - State:NY
Mailing Address - Zip Code:13424-5423
Mailing Address - Country:US
Mailing Address - Phone:315-736-1535
Mailing Address - Fax:
Practice Address - Street 1:1207 UTICA ST
Practice Address - Street 2:
Practice Address - City:ORISKANY
Practice Address - State:NY
Practice Address - Zip Code:13424-5423
Practice Address - Country:US
Practice Address - Phone:315-736-1535
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-19
Last Update Date:2020-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023597103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical