Healthcare Provider Details

I. General information

NPI: 1144672437
Provider Name (Legal Business Name): TARA IMMELE LISW-S
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2016
Last Update Date: 12/12/2021
Certification Date: 12/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3917 SPRING GROVE AVE
CINCINNATI OH
45223-3302
US

IV. Provider business mailing address

1501 MADISON RD
WALNUT HILLS OH
45206-1706
US

V. Phone/Fax

Practice location:
  • Phone: 513-357-7600
  • Fax:
Mailing address:
  • Phone: 513-354-5200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI 1500767
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number161130
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: