Healthcare Provider Details

I. General information

NPI: 1316566474
Provider Name (Legal Business Name): TY BRUMBACK PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2020
Last Update Date: 04/09/2020
Certification Date: 04/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3380 ERIE AVE STE 202
CINCINNATI OH
45208-1626
US

IV. Provider business mailing address

7060 JEANNIE AVE
CINCINNATI OH
45230-4031
US

V. Phone/Fax

Practice location:
  • Phone: 513-400-5905
  • Fax:
Mailing address:
  • Phone: 859-572-1484
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberP.08007
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License NumberP.08007
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License NumberP.08007
License Number StateOH
# 4
Primary TaxonomyN
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License NumberP.08007
License Number StateOH
# 5
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberP.08007
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: