Provider Demographics
NPI:1184079030
Name:LIBBY TANNENBAUM LLC
Entity type:Organization
Organization Name:LIBBY TANNENBAUM LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LIBBY
Authorized Official - Middle Name:
Authorized Official - Last Name:TANNENBAUM
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:404-281-6477
Mailing Address - Street 1:11755 POINTE PL
Mailing Address - Street 2:SUITE A-1
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-4656
Mailing Address - Country:US
Mailing Address - Phone:404-281-6477
Mailing Address - Fax:
Practice Address - Street 1:11755 POINTE PL
Practice Address - Street 2:SUITE A-1
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-4656
Practice Address - Country:US
Practice Address - Phone:404-281-6477
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-28
Last Update Date:2016-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY2710251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health