Provider Demographics
NPI:1528710662
Name:TANNEBAUM, ELLEN RUTH
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:RUTH
Last Name:TANNEBAUM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4193 FALLOW DR
Mailing Address - Street 2:
Mailing Address - City:HAMPSTEAD
Mailing Address - State:MD
Mailing Address - Zip Code:21074-2587
Mailing Address - Country:US
Mailing Address - Phone:410-736-9233
Mailing Address - Fax:
Practice Address - Street 1:7001 JOHNNYCAKE RD
Practice Address - Street 2:
Practice Address - City:WINDSOR MILL
Practice Address - State:MD
Practice Address - Zip Code:21244-2418
Practice Address - Country:US
Practice Address - Phone:410-774-9840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-20
Last Update Date:2022-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst