Basic Information
| Provider Information | |||||||||
| NPI: | 1396107173 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EIDSON | ||||||||
| FirstName: | TAMMY | ||||||||
| MiddleName: | |||||||||
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| Credential: | LISW, MSW, LSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 305 N 5TH ST | ||||||||
| Address2: | |||||||||
| City: | IRONTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456381578 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7405324858 | ||||||||
| FaxNumber: | 7405324859 | ||||||||
| Practice Location | |||||||||
| Address1: | 55 TOWNSHIP ROAD 508 E | ||||||||
| Address2: | |||||||||
| City: | SOUTH POINT | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456807276 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403772712 | ||||||||
| FaxNumber: | 7403772588 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2016 | ||||||||
| LastUpdateDate: | 03/17/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | S1201580 | OH | N | Behavioral Health & Social Service Providers | Social Worker | 104100000X | I.1700020 | OH | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | I1700020 | 01 | OH | OHIO LICENSE | OTHER |