Provider Demographics
NPI:1720178692
Name:TANNER, GALEN L (MA)
Entity Type:Individual
Prefix:MR
First Name:GALEN
Middle Name:L
Last Name:TANNER
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3016 QUINCY LN
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60504-6806
Mailing Address - Country:US
Mailing Address - Phone:331-725-8342
Mailing Address - Fax:
Practice Address - Street 1:4320 WINFIELD RD
Practice Address - Street 2:SUITE 200
Practice Address - City:WARRENVILLE
Practice Address - State:IL
Practice Address - Zip Code:60555-4018
Practice Address - Country:US
Practice Address - Phone:331-725-8342
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL166-000603106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist