Provider Demographics
NPI:1144672437
Name:IMMELE, TARA (LISW-S)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:IMMELE
Suffix:
Gender:F
Credentials:LISW-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 MADISON RD
Mailing Address - Street 2:
Mailing Address - City:WALNUT HILLS
Mailing Address - State:OH
Mailing Address - Zip Code:45206-1706
Mailing Address - Country:US
Mailing Address - Phone:513-354-5200
Mailing Address - Fax:
Practice Address - Street 1:3917 SPRING GROVE AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45223-3302
Practice Address - Country:US
Practice Address - Phone:513-357-7600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-11
Last Update Date:2021-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI 15007671041C0700X
OH161130101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)