MEDICARE: TINA LASHON ROEBUCK

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	104100000X	Social Worker	S.1303479	OH
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	LCDCII.161420	OH

General Provider Information

NPI Number	:	1174000582
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TINA LASHON ROEBUCK

Provider Business Mailing Address
First Line	:	624 UNION ST
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45229-3338
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2605 WOODBURN AVE
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45206-1712
Country	:	US
Telephone Number	:	513-946-9561
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/27/2018
Last Update Date	:	07/27/2018

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Directions to “ TINA LASHON ROEBUCK ” Practice Location

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