Provider Demographics
NPI:1386374585
Name:TANNER, MACKENZIE (PHD)
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:
Last Name:TANNER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5877 STAGHORN DR
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43614-4564
Mailing Address - Country:US
Mailing Address - Phone:937-776-4995
Mailing Address - Fax:
Practice Address - Street 1:8163 GRAND RIVER RD STE 100
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:MI
Practice Address - Zip Code:48114-9482
Practice Address - Country:US
Practice Address - Phone:810-225-3417
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-13
Last Update Date:2025-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist