Provider Demographics
NPI:1649481540
Name:TANKS, ROSE MARY (LISW-S,LICDC-CS,LPN)
Entity type:Individual
Prefix:MS
First Name:ROSE
Middle Name:MARY
Last Name:TANKS
Suffix:
Gender:F
Credentials:LISW-S,LICDC-CS,LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6012 DESMOND STREET
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45227-1812
Mailing Address - Country:US
Mailing Address - Phone:513-213-7208
Mailing Address - Fax:513-271-7697
Practice Address - Street 1:6012 DESMOND STREET
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45227-1812
Practice Address - Country:US
Practice Address - Phone:513-213-7208
Practice Address - Fax:513-271-7697
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-24
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH965748101YA0400X
OH1.0010124104100000X
OHPN-049022164W00000X
OH3115042171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No164W00000XNursing Service ProvidersLicensed Practical Nurse
No171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3152743Medicaid
OH965748OtherOHIO PROFESSIONAL CHEMICAL DEPENDENCY BOARD
OHI.10010124OtherOHIO FAMILY COUNSELING AND SOCIAL WORKER BOARD
OHPN.049022 MEDSOtherOHIO NURSING BOARD