Healthcare Provider Details

I. General information

NPI: 1942436837
Provider Name (Legal Business Name): TARA TODD LINEWEAVER PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2009
Last Update Date: 06/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9531 VALPARAISO CT
INDIANAPOLIS IN
46268-1130
US

IV. Provider business mailing address

1854 RELIABLE PKWY
CHICAGO IL
60686-0001
US

V. Phone/Fax

Practice location:
  • Phone: 317-879-8940
  • Fax: 317-872-0914
Mailing address:
  • Phone: 270-744-9600
  • Fax: 270-744-0834

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number20041964A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: