Provider Demographics
NPI:1720669955
Name:TANNER, HOLLY K
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:K
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:PO BOX 29
Mailing Address - Street 2:
Mailing Address - City:ARIMO
Mailing Address - State:ID
Mailing Address - Zip Code:83214-0029
Mailing Address - Country:US
Mailing Address - Phone:208-317-3899
Mailing Address - Fax:
Practice Address - Street 1:150 S FRONT ST
Practice Address - Street 2:
Practice Address - City:ARIMO
Practice Address - State:ID
Practice Address - Zip Code:83214-7726
Practice Address - Country:US
Practice Address - Phone:208-317-3899
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-19
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchoolGroup - Single Specialty