Provider Demographics
NPI:1477639474
Name:TANNER, DANITA (LMSW)
Entity type:Individual
Prefix:
First Name:DANITA
Middle Name:
Last Name:TANNER
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:538 N PASEO DE ONATE
Mailing Address - Street 2:P.O. BOX 158
Mailing Address - City:ESPANOLA
Mailing Address - State:NM
Mailing Address - Zip Code:87532-2618
Mailing Address - Country:US
Mailing Address - Phone:505-753-7218
Mailing Address - Fax:505-753-5815
Practice Address - Street 1:1235 EIGHTH ST.
Practice Address - Street 2:EL CENTRO FAMILY HEALTH LAS VEGAS CLINIC
Practice Address - City:LAS VEGAS
Practice Address - State:NM
Practice Address - Zip Code:87701-4219
Practice Address - Country:US
Practice Address - Phone:505-425-6788
Practice Address - Fax:505-425-5408
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2013-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMM-08229104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker