Provider Demographics
NPI:1942436837
Name:LINEWEAVER, TARA TODD (PHD)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:TODD
Last Name:LINEWEAVER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1854 RELIABLE PKWY
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60686-0001
Mailing Address - Country:US
Mailing Address - Phone:270-744-9600
Mailing Address - Fax:270-744-0834
Practice Address - Street 1:9531 VALPARAISO CT
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46268-1130
Practice Address - Country:US
Practice Address - Phone:317-879-8940
Practice Address - Fax:317-872-0914
Is Sole Proprietor?:No
Enumeration Date:2009-06-05
Last Update Date:2011-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20041964A103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200944120Medicaid
INM400023396Medicare PIN