Basic Information
| Provider Information | |||||||||
| NPI: | 1790054260 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HEINL | ||||||||
| FirstName: | TARA | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | LISW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7140 OFFICE PARK DR | ||||||||
| Address2: | |||||||||
| City: | WEST CHESTER | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450692261 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5137772428 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1490 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432052140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6142516468 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2011 | ||||||||
| LastUpdateDate: | 11/09/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 1000091 | OH | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 0213588 | 05 | OH | MEDICAID |