Basic Information
| Provider Information | |||||||||
| NPI: | 1063087104 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WITHROW | ||||||||
| FirstName: | TRISTICA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3103 DIXIE HWY | ||||||||
| Address2: | |||||||||
| City: | HAMILTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450151653 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5138924673 | ||||||||
| FaxNumber: | 5137371107 | ||||||||
| Practice Location | |||||||||
| Address1: | 6570 SOSNA DR | ||||||||
| Address2: | |||||||||
| City: | FAIRFIELD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450142222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5139424673 | ||||||||
| FaxNumber: | 5138601439 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/21/2021 | ||||||||
| LastUpdateDate: | 05/04/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | C.2203992-TRNE | OH | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 101YA0400X | C.2203992-TRNE | OH | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.