Provider Demographics
NPI:1699202069
Name:DANNELLY, TANDA (MSW)
Entity type:Individual
Prefix:
First Name:TANDA
Middle Name:
Last Name:DANNELLY
Suffix:
Gender:F
Credentials:MSW
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 802
Mailing Address - Street 2:
Mailing Address - City:BEREA
Mailing Address - State:KY
Mailing Address - Zip Code:40403-0802
Mailing Address - Country:US
Mailing Address - Phone:859-986-5452
Mailing Address - Fax:859-972-0616
Practice Address - Street 1:292 GLADES RD STE 8
Practice Address - Street 2:
Practice Address - City:BEREA
Practice Address - State:KY
Practice Address - Zip Code:40403-1368
Practice Address - Country:US
Practice Address - Phone:859-985-7862
Practice Address - Fax:859-972-0616
Is Sole Proprietor?:No
Enumeration Date:2017-05-17
Last Update Date:2017-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator