Provider Demographics
NPI:1538179346
Name:TANN, MELVIN AVON (ACSW, LCSW)
Entity type:Individual
Prefix:MR
First Name:MELVIN
Middle Name:AVON
Last Name:TANN
Suffix:
Gender:M
Credentials:ACSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7750 CLAYTON RD STE 300
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63117-1341
Mailing Address - Country:US
Mailing Address - Phone:314-644-4600
Mailing Address - Fax:314-644-3274
Practice Address - Street 1:7750 CLAYTON RD STE 300
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63117-1341
Practice Address - Country:US
Practice Address - Phone:314-644-4600
Practice Address - Fax:314-644-3274
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2012-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOSW0039131041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO496893306Medicaid
MO193237459OtherMEDICARE ORGANIZATION NPI
MO193237459OtherMEDICARE ORGANIZATION NPI
MO481266367OtherTAX ID NUMBER