Basic Information
| Provider Information | |||||||||
| NPI: | 1093204596 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ETTER | ||||||||
| FirstName: | TAMI | ||||||||
| MiddleName: | DAWN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MSW, LSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GROSS | ||||||||
| OtherFirstName: | TAMI | ||||||||
| OtherMiddleName: | D | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MSW, LSW | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 280 MONTGOMERY LN | ||||||||
| Address2: | |||||||||
| City: | SPRINGBORO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450665018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372842051 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1879 DEERFIELD RD | ||||||||
| Address2: | |||||||||
| City: | LEBANON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450368602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5136952900 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2018 | ||||||||
| LastUpdateDate: | 06/30/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | S.1701674 | OH | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.