Provider Demographics
NPI:1548812597
Name:LEE, TANNER (OTR/L)
Entity type:Individual
Prefix:
First Name:TANNER
Middle Name:
Last Name:LEE
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15235 ONEAL RD
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-3221
Mailing Address - Country:US
Mailing Address - Phone:601-672-3707
Mailing Address - Fax:
Practice Address - Street 1:8905 OCEAN SPRINGS RD
Practice Address - Street 2:
Practice Address - City:OCEAN SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39564-4419
Practice Address - Country:US
Practice Address - Phone:228-215-0521
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-10
Last Update Date:2019-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSOT3504225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist