Provider Demographics
NPI:1124752118
Name:TRAVIS TANNER
Entity type:Organization
Organization Name:TRAVIS TANNER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER AND CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TRAVIS
Authorized Official - Middle Name:
Authorized Official - Last Name:TANNER
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:917-909-2332
Mailing Address - Street 1:860 LORIMER ST APT 2C
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11222-7531
Mailing Address - Country:US
Mailing Address - Phone:917-909-2332
Mailing Address - Fax:917-909-2340
Practice Address - Street 1:860 LORIMER ST APT 2C
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11222-7531
Practice Address - Country:US
Practice Address - Phone:917-909-2332
Practice Address - Fax:917-909-2340
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-14
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty