Basic Information
| Provider Information | |||||||||
| NPI: | 1801201397 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TANT | ||||||||
| FirstName: | MINDY | ||||||||
| MiddleName: | MICHELLE | ||||||||
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| Credential: | MA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 90 HOWARD DR | ||||||||
| Address2: | |||||||||
| City: | SHELBYVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 400658138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5026331007 | ||||||||
| FaxNumber: | 5024370624 | ||||||||
| Practice Location | |||||||||
| Address1: | 90 HOWARD DR | ||||||||
| Address2: | |||||||||
| City: | SHELBYVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 40065 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5026331007 | ||||||||
| FaxNumber: | 5024370624 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2014 | ||||||||
| LastUpdateDate: | 03/06/2019 | ||||||||
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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 | 103K00000X | 243193 | KY | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
ID Information
| ID | Type | State | Issuer | Description | 1-13-12752 | 01 | IN | BCBA | OTHER |