Healthcare Provider Details

I. General information

NPI: 1104733500
Provider Name (Legal Business Name): TARA LANE
Entity Type: Individual
Gender:
Sole Proprietor: N

Provider Other Name: TARA BOTTOM

II. Dates (important events)

Enumeration Date: 08/24/2026
Last Update Date: 08/24/2026
Certification Date: 08/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1730 MADISON RD
CINCINNATI OH
45206-1865
US

IV. Provider business mailing address

1730 MADISON RD
CINCINNATI OH
45206-1865
US

V. Phone/Fax

Practice location:
  • Phone: 513-549-0160
  • Fax:
Mailing address:
  • Phone: 513-549-0160
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberC.2607882-TRNE
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: