Healthcare Provider Details

I. General information

NPI: 1285115147
Provider Name (Legal Business Name): TAMARA LYNN JUNGE LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2018
Last Update Date: 09/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1252 RALSTON AVENUE #401
DEFIANCE OH
43512
US

IV. Provider business mailing address

1 SEAGATE STE 800
TOLEDO OH
43604-1558
US

V. Phone/Fax

Practice location:
  • Phone: 419-783-6805
  • Fax: 419-783-6804
Mailing address:
  • Phone: 567-585-1918
  • Fax: 419-824-7359

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.1100067-SUPV
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: