Provider Demographics
NPI:1083659445
Name:DECKARD-TANKERSLEY, LAURIE ANN (PSYD)
Entity type:Individual
Prefix:DR
First Name:LAURIE
Middle Name:ANN
Last Name:DECKARD-TANKERSLEY
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:137 MILL SPRING PL
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-4820
Mailing Address - Country:US
Mailing Address - Phone:773-733-6629
Mailing Address - Fax:386-463-2170
Practice Address - Street 1:137 MILL SPRING PL
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-4820
Practice Address - Country:US
Practice Address - Phone:773-733-6629
Practice Address - Fax:386-463-2170
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-19
Last Update Date:2018-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071006688103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical