Provider Demographics
NPI:1962692814
Name:TANNER STAPLETON, LYNLEE RENEE (PHD)
Entity type:Individual
Prefix:
First Name:LYNLEE
Middle Name:RENEE
Last Name:TANNER STAPLETON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:LYNLEE
Other - Middle Name:R
Other - Last Name:TANNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:2121 EISENHOWER AVE
Mailing Address - Street 2:STE 230
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22314-4698
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2121 EISENHOWER AVE
Practice Address - Street 2:STE 230
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22314-4698
Practice Address - Country:US
Practice Address - Phone:202-999-9999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-26
Last Update Date:2017-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103T00000X
VA0810005048103TC0700X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist