Provider Demographics
NPI:1790296531
Name:WOLTZ, TARA RENEE (LPC)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:RENEE
Last Name:WOLTZ
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3964 HAMILTON SQUARE BLVD
Mailing Address - Street 2:
Mailing Address - City:GROVEPORT
Mailing Address - State:OH
Mailing Address - Zip Code:43125-9119
Mailing Address - Country:US
Mailing Address - Phone:614-610-1506
Mailing Address - Fax:
Practice Address - Street 1:3964 HAMILTON SQUARE BLVD
Practice Address - Street 2:
Practice Address - City:GROVEPORT
Practice Address - State:OH
Practice Address - Zip Code:43125-9119
Practice Address - Country:US
Practice Address - Phone:614-610-1506
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-19
Last Update Date:2017-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1400647101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1093251225OtherPRIVATE INS