Healthcare Provider Details

I. General information

NPI: 1477949592
Provider Name (Legal Business Name): TASHA MONIQUE WADLEY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2015
Last Update Date: 07/29/2024
Certification Date: 07/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3333 BURNET AVE ML 5026
CINCINNATI OH
45229
US

IV. Provider business mailing address

3333 BURNET AVE MLC 2011
CINCINNATI OH
45229-3026
US

V. Phone/Fax

Practice location:
  • Phone: 513-636-7722
  • Fax: 513-636-3737
Mailing address:
  • Phone: 513-636-7722
  • Fax: 513-636-3737

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35.133512
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number55964
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: