Basic Information
| Provider Information | |||||||||
| NPI: | 1477713170 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TANNER | ||||||||
| FirstName: | ASHLEY | ||||||||
| MiddleName: | BROOKE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 116 COLUMBIA AVE | ||||||||
| Address2: | |||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132071608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9175963135 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | HUTCHINGS PSYCHIATRIC CENTER | ||||||||
| Address2: | 620 MADISON ST | ||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 13210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154263600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2008 | ||||||||
| LastUpdateDate: | 06/12/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 078955 | NY | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.