Healthcare Provider Details

I. General information

NPI: 1093179897
Provider Name (Legal Business Name): TADESSE M BANTIRGU LSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2016
Last Update Date: 08/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 MARTIN LUTHER KING DR E
CINCINNATI OH
45219-2581
US

IV. Provider business mailing address

311 MARTIN LUTHER KING DR E
CINCINNATI OH
45219-2581
US

V. Phone/Fax

Practice location:
  • Phone: 513-475-5312
  • Fax: 513-332-0367
Mailing address:
  • Phone: 513-475-5312
  • Fax: 513-332-0367

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number021324
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberS-0024418
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: