Provider Demographics
NPI:1669916953
Name:TANNER, SUSAN EMERALD
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:EMERALD
Last Name:TANNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2551 E COUNTY ROAD 62E
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:CO
Mailing Address - Zip Code:80549-1502
Mailing Address - Country:US
Mailing Address - Phone:318-446-3238
Mailing Address - Fax:970-295-4052
Practice Address - Street 1:2551 E COUNTY ROAD 62E
Practice Address - Street 2:
Practice Address - City:WELLINGTON
Practice Address - State:CO
Practice Address - Zip Code:80549-1502
Practice Address - Country:US
Practice Address - Phone:318-446-3238
Practice Address - Fax:970-295-4052
Is Sole Proprietor?:No
Enumeration Date:2016-12-06
Last Update Date:2016-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician