Provider Demographics
NPI:1801531538
Name:COONE, TANNER (RADT 1)
Entity type:Individual
Prefix:
First Name:TANNER
Middle Name:
Last Name:COONE
Suffix:
Gender:M
Credentials:RADT 1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4320 TRIAS ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-1127
Mailing Address - Country:US
Mailing Address - Phone:254-299-7555
Mailing Address - Fax:
Practice Address - Street 1:4141 PACIFIC HWY
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-2030
Practice Address - Country:US
Practice Address - Phone:619-393-2052
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-27
Last Update Date:2022-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1461280322101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)