Healthcare Provider Details

I. General information

NPI: 1164378659
Provider Name (Legal Business Name): TANNER CLARK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/06/2026
Last Update Date: 03/06/2026
Certification Date: 03/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7593 TYLERS PLACE BLVD
WEST CHESTER OH
45069-6308
US

IV. Provider business mailing address

1272 OAKMONT AVE
HAMILTON OH
45013-3858
US

V. Phone/Fax

Practice location:
  • Phone: 513-714-3400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA.194817
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: