Provider Demographics
NPI:1699326090
Name:SLATER, TANYA LANE
Entity type:Individual
Prefix:
First Name:TANYA
Middle Name:LANE
Last Name:SLATER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13971 N CLEVELAND AVE STE 9
Mailing Address - Street 2:
Mailing Address - City:NORTH FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33903-4392
Mailing Address - Country:US
Mailing Address - Phone:239-997-7770
Mailing Address - Fax:239-997-7776
Practice Address - Street 1:13971 N CLEVELAND AVE STE 9
Practice Address - Street 2:
Practice Address - City:NORTH FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33903-4392
Practice Address - Country:US
Practice Address - Phone:239-997-7770
Practice Address - Fax:239-997-7776
Is Sole Proprietor?:No
Enumeration Date:2019-09-26
Last Update Date:2019-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL50516101YA0400X
FL121425101YA0400X
FL190101YA0400X
FLADC011451-2015101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)