Provider Demographics
NPI:1043580202
Name:DALE, TARA K (LISW)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:K
Last Name:DALE
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3333 BURNET AVE
Mailing Address - Street 2:MLC 6019
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45229-3026
Mailing Address - Country:US
Mailing Address - Phone:513-636-4124
Mailing Address - Fax:513-636-4283
Practice Address - Street 1:3333 BURNET AVE
Practice Address - Street 2:MLC 6019
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45229-3026
Practice Address - Country:US
Practice Address - Phone:513-636-4124
Practice Address - Fax:513-636-4283
Is Sole Proprietor?:No
Enumeration Date:2012-01-05
Last Update Date:2016-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.1303052-SUPV104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker