Provider Demographics
NPI:1124328604
Name:TANNENBAUM, DEBORAH L (MSW, LCSW)
Entity type:Individual
Prefix:MS
First Name:DEBORAH
Middle Name:L
Last Name:TANNENBAUM
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:MS
Other - First Name:DEBORAH
Other - Middle Name:L
Other - Last Name:FREDMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3000 ARROW ROCK DR
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63303-6502
Mailing Address - Country:US
Mailing Address - Phone:314-303-2762
Mailing Address - Fax:
Practice Address - Street 1:4625 LINDELL BLVD FL 2
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63108-3739
Practice Address - Country:US
Practice Address - Phone:636-486-6356
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-29
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0049361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOMA3274Medicare PIN