Provider Demographics
NPI:1306604863
Name:TANNER, AMANDA ELIZABETH (MA)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:ELIZABETH
Last Name:TANNER
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4837
Mailing Address - Street 2:
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87305-4837
Mailing Address - Country:US
Mailing Address - Phone:505-879-9938
Mailing Address - Fax:
Practice Address - Street 1:515 PARK AVE
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-5806
Practice Address - Country:US
Practice Address - Phone:505-879-9938
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-11
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCTB-2023-0077101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health