Healthcare Provider Details

I. General information

NPI: 1649481540
Provider Name (Legal Business Name): ROSE MARY TANKS LISW-S,LICDC-CS,LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2007
Last Update Date: 08/10/2023
Certification Date: 08/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6012 DESMOND STREET
CINCINNATI OH
45227-1812
US

IV. Provider business mailing address

6012 DESMOND STREET
CINCINNATI OH
45227-1812
US

V. Phone/Fax

Practice location:
  • Phone: 513-213-7208
  • Fax: 513-271-7697
Mailing address:
  • Phone: 513-213-7208
  • Fax: 513-271-7697

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number965748
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number1.0010124
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberPN-049022
License Number StateOH
# 4
Primary TaxonomyN
Taxonomy Code171W00000X
TaxonomyContractor
License Number3115042
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: