Provider Demographics
NPI:1205512191
Name:TENNANT, ELENA CUCLIS (LMSW)
Entity type:Individual
Prefix:
First Name:ELENA
Middle Name:CUCLIS
Last Name:TENNANT
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 SPRUCE ST NE APT 24
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30307
Mailing Address - Country:US
Mailing Address - Phone:707-227-6269
Mailing Address - Fax:
Practice Address - Street 1:2751 BUFORD HWY #204
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30324
Practice Address - Country:US
Practice Address - Phone:404-994-8282
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-26
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMSW010182104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker