Provider Demographics
NPI:1184293052
Name:UNDERWOOD, TIA NICOLE
Entity type:Individual
Prefix:MS
First Name:TIA
Middle Name:NICOLE
Last Name:UNDERWOOD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:146 CHESHIRE CROSSING DR
Mailing Address - Street 2:
Mailing Address - City:DELAWARE
Mailing Address - State:OH
Mailing Address - Zip Code:43015-8316
Mailing Address - Country:US
Mailing Address - Phone:614-962-3691
Mailing Address - Fax:
Practice Address - Street 1:146 CHESHIRE CROSSING DR
Practice Address - Street 2:
Practice Address - City:DELAWARE
Practice Address - State:OH
Practice Address - Zip Code:43015-8316
Practice Address - Country:US
Practice Address - Phone:614-962-3691
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-23
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 103TA0400X, 171M00000X
OH101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator