Healthcare Provider Details

I. General information

NPI: 1205554847
Provider Name (Legal Business Name): TARA NICOLE EADES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2022
Last Update Date: 08/19/2022
Certification Date: 08/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1411 N FAIRFIELD RD
BEAVERCREEK OH
45432-2637
US

IV. Provider business mailing address

1411 N FAIRFIELD RD
BEAVERCREEK OH
45432-2637
US

V. Phone/Fax

Practice location:
  • Phone: 937-426-2686
  • Fax: 937-426-6230
Mailing address:
  • Phone: 937-426-2686
  • Fax: 937-426-6230

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: