Healthcare Provider Details

I. General information

NPI: 1467295030
Provider Name (Legal Business Name): TARA J KOBASKO QMHS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2024
Last Update Date: 06/13/2024
Certification Date: 06/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

165 OWINGS ST
WEIRTON WV
26062-2338
US

IV. Provider business mailing address

321 W 5TH ST
EAST LIVERPOOL OH
43920-2849
US

V. Phone/Fax

Practice location:
  • Phone: 304-215-6561
  • Fax:
Mailing address:
  • Phone: 330-385-8800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: