Provider Demographics
NPI:1740293273
Name:TANIS, MICHAEL A (EDS, LMFT)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:A
Last Name:TANIS
Suffix:
Gender:M
Credentials:EDS, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 1187
Mailing Address - Street 2:
Mailing Address - City:HUNTERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28070-1187
Mailing Address - Country:US
Mailing Address - Phone:704-892-4082
Mailing Address - Fax:704-892-4082
Practice Address - Street 1:19501 W CATAWBA AVE
Practice Address - Street 2:SUITE 205
Practice Address - City:CORNELIUS
Practice Address - State:NC
Practice Address - Zip Code:28031-4017
Practice Address - Country:US
Practice Address - Phone:704-892-4082
Practice Address - Fax:704-892-4082
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2009-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3801101YP2500X
SC4101101YP2500X
NC875106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional