Provider Demographics
NPI:1932852944
Name:TANIS, DIANNE
Entity Type:Individual
Prefix:
First Name:DIANNE
Middle Name:
Last Name:TANIS
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 1:1501 PARKSIDE AVE APT 13N
Mailing Address - Street 2:
Mailing Address - City:EWING
Mailing Address - State:NJ
Mailing Address - Zip Code:08638-2632
Mailing Address - Country:US
Mailing Address - Phone:973-204-6334
Mailing Address - Fax:
Practice Address - Street 1:1501 PARKSIDE AVE APT 13N
Practice Address - Street 2:
Practice Address - City:EWING
Practice Address - State:NJ
Practice Address - Zip Code:08638-2632
Practice Address - Country:US
Practice Address - Phone:973-204-6334
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-31
Last Update Date:2022-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool