Provider Demographics
NPI:1093179897
Name:BANTIRGU, TADESSE M (LSW)
Entity Type:Individual
Prefix:DR
First Name:TADESSE
Middle Name:M
Last Name:BANTIRGU
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 MARTIN LUTHER KING DR E
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45219-2581
Mailing Address - Country:US
Mailing Address - Phone:513-475-5312
Mailing Address - Fax:513-332-0367
Practice Address - Street 1:311 MARTIN LUTHER KING DR E
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45219-2581
Practice Address - Country:US
Practice Address - Phone:513-475-5312
Practice Address - Fax:513-332-0367
Is Sole Proprietor?:No
Enumeration Date:2016-04-07
Last Update Date:2016-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS-00244181041C0700X
OH021324101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)