Provider Demographics
NPI:1548869183
Name:TANNER, MICHAEL (LMFT)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:TANNER
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5763 VILLAGE LOOP
Mailing Address - Street 2:
Mailing Address - City:FAIRBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30213-4641
Mailing Address - Country:US
Mailing Address - Phone:770-377-1563
Mailing Address - Fax:
Practice Address - Street 1:5763 VILLAGE LOOP
Practice Address - Street 2:
Practice Address - City:FAIRBURN
Practice Address - State:GA
Practice Address - Zip Code:30213-4641
Practice Address - Country:US
Practice Address - Phone:770-377-1563
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-24
Last Update Date:2020-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALMFT001813106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty