MEDICARE: TARA TODD LINEWEAVER PHD

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	103T00000X	Psychologist	20041964A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1942436837
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TARA TODD LINEWEAVER PHD

Provider Business Mailing Address
First Line	:	1854 RELIABLE PKWY
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60686-0001
Country	:	US
Telephone Number	:	270-744-9600
Fax Number	:	270-744-0834

Provider Business Practice Location Address
First Line	:	9531 VALPARAISO CT
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46268-1130
Country	:	US
Telephone Number	:	317-879-8940
Fax Number	:	317-872-0914

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

Provider Enumeration Date	:	06/05/2009
Last Update Date	:	06/06/2011

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