Provider Demographics
NPI:1740806322
Name:SHADOWENS, LARA TALENA (MSW, LISW)
Entity Type:Individual
Prefix:MRS
First Name:LARA
Middle Name:TALENA
Last Name:SHADOWENS
Suffix:
Gender:F
Credentials:MSW, LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 PARKTRACE CT
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45238-6296
Mailing Address - Country:US
Mailing Address - Phone:513-218-2828
Mailing Address - Fax:
Practice Address - Street 1:1080 NIMITZVIEW DR STE 101
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45230-4300
Practice Address - Country:US
Practice Address - Phone:513-327-8878
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-19
Last Update Date:2024-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.24051851041C0700X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0455673Medicaid
OH15791290OtherCAQH