Provider Demographics
NPI:1750719407
Name:TANNER, TERRENCE (LCSW)
Entity type:Individual
Prefix:MR
First Name:TERRENCE
Middle Name:
Last Name:TANNER
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 COAST GUARD BLVD
Mailing Address - Street 2:HSWL
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23703-2135
Mailing Address - Country:US
Mailing Address - Phone:757-686-4036
Mailing Address - Fax:757-686-4094
Practice Address - Street 1:4000 COAST GUARD BLVD
Practice Address - Street 2:HSWL
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23703-2135
Practice Address - Country:US
Practice Address - Phone:757-686-4036
Practice Address - Fax:757-686-4094
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-16
Last Update Date:2013-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0904005040101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health