1013281815 NPI number — DR. LIBBY ROSE TANNENBAUM PH.D.

Table of content: DR. LIBBY ROSE TANNENBAUM PH.D. (NPI 1013281815)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013281815 NPI number — DR. LIBBY ROSE TANNENBAUM PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TANNENBAUM
Provider First Name:
LIBBY
Provider Middle Name:
ROSE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1013281815
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/27/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2440 LAWRENCEVILLE HWY
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
DECATUR
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30033-3266
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-634-3400
Provider Business Mailing Address Fax Number:
404-634-3482

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2440 LAWRENCEVILLE HWY
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
DECATUR
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30033-3266
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-634-3400
Provider Business Practice Location Address Fax Number:
404-634-3482
Provider Enumeration Date:
02/27/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  PSY002710 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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