Provider Demographics
NPI:1861161036
Name:FOUT, TARA (SWT)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:FOUT
Suffix:
Gender:F
Credentials:SWT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:656 CHERRY ST E
Mailing Address - Street 2:
Mailing Address - City:CANAL FULTON
Mailing Address - State:OH
Mailing Address - Zip Code:44614-1251
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2587 BACK ORRVILLE RD
Practice Address - Street 2:
Practice Address - City:WOOSTER
Practice Address - State:OH
Practice Address - Zip Code:44691-9523
Practice Address - Country:US
Practice Address - Phone:330-264-9597
Practice Address - Fax:330-264-0946
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-10
Last Update Date:2022-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3747P1801X, 172A00000X
OHS.2202416-TRNE104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0311090Medicaid