1770967317 NPI number — MRS. ALEXIA MICHELLE TANNER LCSW

Table of content: TARA MALONEY LCSW (NPI 1710316849)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770967317 NPI number — MRS. ALEXIA MICHELLE TANNER LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TANNER
Provider First Name:
ALEXIA
Provider Middle Name:
MICHELLE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MORGAN
Provider Other First Name:
ALEXIA
Provider Other Middle Name:
MICHELLE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1770967317
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/02/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 2707
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TIFTON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31793-0909
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
229-388-0932
Provider Business Mailing Address Fax Number:
229-388-0933

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
911 MAIN ST S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TIFTON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31794-4867
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
229-396-4689
Provider Business Practice Location Address Fax Number:
229-396-4605
Provider Enumeration Date:
07/14/2015

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: 1041C0700X , with the licence number:  CSW005210 , 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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