Provider Demographics
NPI:1811371727
Name:TANNER, TRAVIS (LCSW)
Entity type:Individual
Prefix:
First Name:TRAVIS
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 1:3149 36TH ST APT 4C
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11106-1055
Mailing Address - Country:US
Mailing Address - Phone:917-909-2332
Mailing Address - Fax:917-909-2336
Practice Address - Street 1:225 W 35TH ST FL 7
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001-1904
Practice Address - Country:US
Practice Address - Phone:917-909-2332
Practice Address - Fax:917-909-2336
Is Sole Proprietor?:No
Enumeration Date:2015-07-10
Last Update Date:2019-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0875991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical