Provider Demographics
NPI:1306151519
Name:TANNER, BRYAN SCOTT (BCBA)
Entity type:Individual
Prefix:MR
First Name:BRYAN
Middle Name:SCOTT
Last Name:TANNER
Suffix:
Gender:M
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2551 E COUNTY ROAD 62E
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:CO
Mailing Address - Zip Code:80549-1502
Mailing Address - Country:US
Mailing Address - Phone:318-638-4621
Mailing Address - Fax:
Practice Address - Street 1:2551 E COUNTY ROAD 62E
Practice Address - Street 2:
Practice Address - City:WELLINGTON
Practice Address - State:CO
Practice Address - Zip Code:80549-1502
Practice Address - Country:US
Practice Address - Phone:318-638-4621
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-11
Last Update Date:2016-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-09-5044103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
1-09-5044OtherBACB CERTIFICATION NUMBER.